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Home My WebLink AboutDON KEHN - INSURANCE CERTIFICATE (3)c111anl$•91172 nAuwCIAW4 ACORID- CERTIFICATE OF LIABILITY INSURANCE DIDDIYYYY) 10/0410J04/05 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 P.O. Box 469025 HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Denver, CO 80246-9025 INSURERS AFFORDING COVERAGE NAIC # INSURED Don Kohn Construction, Inc. 6550 SCRS INSURER A: Travelers Indemnity Company 25658 INSURERS: Pinnacol Assurance 10780 Fort Collins, CO 80526 INSURER C: INSURER D: INSURER E: COVERAGES 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. LTR N R TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE DATE (MMIDDffYI POLICY EXPIRATION DATE Y LIMITS A GENERAL LIABILITY X COMMERCIAL GENERAL LIABILITY CLAIMS MADE a OCCUR AI# CGD2520103 - DTC0161ES893IND04 11/01/04 11/01/05 EACH OCCURRENCE $1 00Q 000 DAMAGE TO RENTED MED EXP (Any one person) $300OOO $5 000 PERSONAL&ADV INJURY $1 00O 000 X Ltd Pollution GENERAL AGGREGATE s2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: POLICY X PRO ECT X LOC PRODUCTS - COMP/OP AGG $2 00O 000 A AUTOMOBILE LIABILITY ANY AUTO ALL OWNED AUTOS SCHEDULEDAUTOS HIREDAUTOS NON -OWNED AUTOS Ltd Pollution DT810161E8893TIL04 11/01/04 11/01/05 COMBINED SINGLE LIMIT (Ea accident) $1,000,000 X BODILY INJURY (Per person) $ X BODILY INJURY (Per accident) $ X X PROPERTY DAMAGE (Per accident) $ GARAGE LIABILITY ANY AUTO AUTO ONLY - EA ACCIDENT $ OTHER THAN EA ACC AUTO ONLY: AGG $ $ A EXCESSIUMBRELLALIABILITY X OCCUR CLAIMS MADE DEDUCTIBLE X RETENTION $ 10y000 DTSMJCUP161E8893TI 11/01/04 11/01/05 EACH OCCURRENCE $2000000 AGGREGATE s2 0OO 0OO $ B WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANY PROPRIETOR/PARTNERIEXECUTIVE OFFICERIMEMBER EXCLUDED? If yes, describe under SPECIAL PROVISIONS below 2093950 10/01/05 10/01/06 X WCSTATUMIT- OTH- PP E.L. EACH ACCIDENT $50O 000 E.L. DISEASE - EA EMPLOYEE $500,000 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: Ziegler Road Widening Bid Number: 5834 (See Attached Descriptions) City of Ft. Collins 215 North Mason Street, 2nd Floor Box 580 Fort Collins, CO 80522 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL In* 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 'u.umu AD tzUUTIUV) 1 Of 3 #M267500 MAS 0 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. AUVRV L7-A tAvullua) 2 of 3 #M267500 - DESCRIPTIONS (Continued from Page 1) 1 The following are Additional Insureds as respects General Liability only 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 hMa zo.a tzuu11ua) 3 OT 3 SMz515uu 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 c) This insurance does not apply to "bodily in- to include any person or organization you are re- jury" or "property damage" caused by "your quired to include as an additional insured on this work" included in the "products -completed policy by a written contract or written agreement operations hazard". in effect during this policy period and signed and d) This insurance does not apply to any person executed by you prior to the loss for which cover- or organization for whom you have procured age is sought. The person or organization does separate liability insurance while such insur- not qualify as an additional insured with respect to ance is in effect, regardless of whether the the independent acts or omissions of such person scope or limits of insurance in this policy ex - or organization. The person or organization is ceed those of such other insurance or only an additional insured with respect to liability whether such other insurance is valid or col - caused by "your work" for that additional insured. lectable. 2. The insurance provided to the additional insured 3. Subpart (1)(a) of the Pollution exclusion under is limited as follows: Paragraph 2., Exclusions of Bodily Injury and a) In the event that the limits of liability stated in Property Damage Liability Coverage (Section I - the policy exceed the limits of liability required Coverages) does not apply to you if the "bodily .= by a written contract or written agreement in injury" or "property damage" arises out of "your �— effect during this policy period and signed and work performed on premises which are owned or executed by you prior to the loss for which rented by the additional insured at the time "your "= coverage is sought, the insurance provided work" is performed. by this endorsement shall be limited to the 4. Any coverage provided by this endorsement to an limits of liability required by such contract or additional insured shall be excess over any other agreement. This endorsement shall not in- valid and collectible insurance available to the o= crease the limits stated in Section III - LIMITS additional insured whether primary, excess, con- _= OF INSURANCE. tingent or on any other basis. m= b) The insurance provided to the additional in- 5. As a condition of coverage, each additional =_ sured does not apply to "bodily injury", "prop- insured must: erty damage", "personal injury" or "advertising a.) Give us prompt written notice of any "occur- �- injury" arising out of an architect's, engineers rence" or offense which may result in a claim �= or surveyors rendering of or failure to render — and prompt written notice of "suit". any professional services including: �— I. The preparing, approving or failing to r b.) Immediately forward all legal papers to us, cooperate in the investigation or settlement of prepare or approve maps, shop drawings, the claim or defense against the "suit," and opinions, reports, surveys, field orders, otherwise comply with policy conditions. change orders, or drawings and specifi- - - --cation:, and- - c.)_Tender_the ._defense and indemnity of any u=_ II. Supervisory or inspection activities per- claim or "suit" to any other insurer which also insures against a loss we cover under this formed as part of any related architectural endorsement. This includes, but is not limited or engineering activities. to, any insurer which has issued a policy of insurance in which the additional insured CG D2 52 01 03 005543 Copyright, The Travelers Indemnity Company, 2003 Page 1 of 2 COMMERCIAL GENERAL LIABILITY qualifies as an insured. For purposes .of this requirement, the term "insures against" refers to any self-insurance and to any insurer which issued a policy of'insurance that rray provide coverage for the loss, regardless of whether the additional insured has actually requested that the insurer provide the additional insured with a defense and/or indemnity under that policy of insurance. a.) Agree 10` make available any other insurance that the additional insured has for a loss we cover under this endorsement. Page 2 of 2 Copyright, The Travelers Indemnity Company, 2003 CG D2 52 01 03 COMMERCIAL GENERAL LIABILITY qualifies as an insured. For purposes .of this requirement, the term "insures against" refers to any self-insurance and to any insurer which issued a policy of'insurance that rray provide coverage for the loss, regardless of whether the additional insured has actually requested that the insurer provide the additional insured with a defense and/or indemnity under that policy of insurance. a.) Agree 10` make available any other insurance that the additional insured has for a loss we cover under this endorsement. Page 2 of 2 Copyright, The Travelers Indemnity Company, 2003 CG D2 52 01 03