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Home My WebLink About102829 DON KEHN CONSTRUCTION INC - INSURANCE CERTIFICATE (10)ACORM CERTIFICATE OF LIABILITY INSURANCE 1DATE 0/04105DmrY> PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION HRH of Colorado ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE 720 S. Colorado Blvd Ste 600-N HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. P.O. Box 469025 Denver, CO 80246-9025 INSURERS AFFORDING COVERAGE NAIC # INSURED INSURER A: Travelers Indemnity Company 25658 Don Kahn Construction, Inc. INSURER B: Pinnacol Assurance 10780 6550 SCRS INSURER C: Fort Collins, CO 80528 INSURER D: INSURER E: r:nVFRAf1FC THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. LTRINSRE TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE DATE MM D POLICY EXPIRATION DATE (MM/DD1YY1 LIMITS A GENERAL LIABILITY DTC0161EB893IND04 11/01/04 11/01/05 EACH OCCURRENCE $1000000 X COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED PREMISES,fEa occurrence) 1300.000 CLAIMS MADE 7 OCCUR MED EXP (Any one person) $5 000 PERSONAL & ADV INJURY $1 000 000 AI# CGD2520103 X Ltd Pollution GENERAL AGGREGATE s2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP/OP AGG s2,000,000 POLICY X PRO- F T X LOC A AUTOMOBILE LIABILITY ANY AUTO DT810161ES893TIL04 11/01/04 11/01105 COMBINED SINGLE LIMIT (Ea accident) $1,000,000 X BODILY INJURY (Per person) $ ALL OWNED AUTOS SCHEDULED AUTOS X BODILY INJURY (Per accident) $ HIREDAUTOS NON -OWNED AUTOS X X PROPERTY DAMAGE (Per accident) $ Ltd Pollution GARAGE LIABILITY AUTO ONLY - EA ACCIDENT $ OTHER THAN EA ACC $ ANY AUTO 1 $ AUTO ONLY: AGG A EXCESSfUMBRELLA LIABILITY DTSMJCUP161 E8893TI 11/01/04 11101/05 EACH OCCURRENCE $2 000 000 X OCCUR CLAIMS MADE AGGREGATE s2,000,000 $ DEDUCTIBLE $ X RETENTION $ 10 000 B WORKERS COMPENSATION AND EMPLOYERS'LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE 2093950 10/01/05 10/01/06 X -IQ C STATUS I JOTH- I ER E.L. EACH ACCIDENT $500 000 E.L. DISEASE - EA EMPLOYEE s500,000 OFFICERIMEMBER EXCLUDED? - If yes, descdbe under SPECIAL PROVISIONS below I E.L. DISEASE - POLICY LIMIT $500,000 OTHER DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS Project Description: Bid #5893/Drake/Ziegler Improvement Project The following are Additional Insureds as respects General Liability only (See Attached Descriptions) City of Fort Collins Administrative Services Purchasing Division P O Box 580 Fort Collins, CO 80522-0580 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL �' Q* DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR AUUKU 25 (ZUUI/US) 1 of 3 #M267500 MAS G ACORD CORPORATION 1988 IMPORTANT If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). DISCLAIMER The Certificate of Insurance on the reverse side of this form does not constitute a contract between the issuing insurer(s), authorized representative or producer, and the certificate holder, nor does it affirmatively or negatively amend, extend or alter the coverage afforded by the policies listed thereon. AUUKU Z5-b (ZUU7/U8) 2 of 3 #M267500 DESCRIPTIONS (Continued from Page 1) 1 if required by written contract and coverage applies only as respects work performed by the Insured for the Additional Insureds. All coverage terms, conditions and exclusions of the policy apply. Additional Insureds: City of Fort Collins. The Additional Insured endorsement which is referenced above under "Type of Insurance -General Liability" is attached. * The following cancellation conditions always apply: - 10 days for non-payment of premium - If policy shown, 10 days for Workers' Compensation for fraud; material misrepresentation; non-payment of premium; other reasons approved by the Commissioner of Insurance AMS 25.3 (2001108) 3 of 3 #M267500 COMMERCIAL GENERAL LIABILITY THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY BLANKET ADDITIONAL INSURED (CONTRACTORS OPERATIONS) This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART COMMERCIAL GENERAL LIABILITY — CONTRACTORS COVERAGE PART 1. WHO IS AN INSURED — (Section II) is amended to include any person or organization you are re- quired to include as an additional insured on this policy by a written contract or written agreement in effect during this policy period and signed and executed by you prior to the loss for which cover- age is sought. The person or organization does not qualify as an additional insured with respect to the independent acts or omissions of such person or organization. The person or organization is only an additional insured with respect to liability caused by "your work" for that additional insured. 2. The insurance provided to the additional insured is limited as follows: a) In the event that the limits of liability stated in the policy exceed the limits of liability required by a written contract or written agreement in effect during this policy period and signed and executed by you prior to the loss for which coverage is sought, the insurance provided by this endorsement shall be limited to the limits of liability required by such contract or .agreement. This endorsement shall not in- crease the limits stated in Section III — LIMITS OF INSURANCE. b) The insurance provided to the additional in- sured does not apply to "bodily injury", "prop- erty damage", "personal injury" or "advertising injury" arising out of an architect's, engineer's or surveyor's rendering of or failure to render any professional services including: I. The preparing, approving or failing to prepare or approve maps, shop drawings, opinions, reports, surveys, field orders, change orders, or drawings and specifi- c) This insurance does not apply to "bodily in- jury" or "property damage" caused by "your work" included in the "products -completed operations hazard". d) This insurance does not apply to any person or organization for whom you have procured separate liability insurance while such insur- ance is in effect, regardless of whether the scope or limits of insurance in this policy ex- ceed those of such other insurance or whether such other insurance is valid or col- lectable. 3. Subpart (1)(a) of the Pollution exclusion under Paragraph 2., Exclusions of Bodily Injury and Property Damage Liability Coverage (Section I — Coverages) does not apply to you if the "bodily injury" or "property damage" arises out of "your work" performed on premises which are owned or rented by the additional insured at the time "your work" is performed. 4. Any coverage provided by this endorsement to an additional insured shall be excess over any other valid and collectible insurance available to the additional insured whether primary, excess, con- tingent or on any other basis. 5. As a condition of coverage, each additional insured must: a.) Give us prompt written notice of any "occur- rence" or offense which may result in a claim and prompt written notice of "suit". b.) Immediately forward all legal papers to us, cooperate in the investigation or settlement of the claim or defense against the "suit," and otherwise comply with policy conditions. _cations; and. _. _ _ _ c,) 11. Supervisory or inspection activities per- formed as part of any related architectural or engineering activities. Tender the defense an in of any claim or "suit" to any other insurer which also insures against a loss we cover under this endorsement. This includes, but is not limited to, any insurer which has issued a policy of insurance in which the additional insured CG D2 52 01 03 008543 Copyright, The Travelers Indemnity Company, 2003 Page 1 of 2