The URL can be used to link to this page

Home My WebLink AboutDON KEHN - INSURANCE CERTIFICATE (5)Client#: 21172 I1IT471 I./ d a: it ACORD- •CERTIFICATE OF LIABILITY INSURANCE DATE (MMID 10/31/05D/YYYY) 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 Kehn Construction, Inc. 6550 SCR5 Fort Collins, CO 80528 INSURER B: Pinnacol Assurance 10780 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. INSK LTR ADD INS TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE DATE DDIM POLICY EXPIRATION DATE 1MM/DDrfYI LIMITS A GENERAL LIABILITY 161E8893 11/01/05 11/01/06 EACH OCCURRENCE $1000000 X COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED PREMISE Me "nce) $300 000 CLAIMS MADE O OCCUR MED EXP (Any one person) $5 000 PERSONAL & ADV INJURY $1 000 000 AI# CG D2 46 (10/02) GENERAL AGGREGATE $2 000 000 GENT AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $2000000 POLICY X dEC X LOC A AUTOMOBILE LIABILITY ANY AUTO 161E8893 11/01/05 11/01/06 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 $ AUTO ONLY: AGG A EXCESS/UMBRELLA LIABILITY 161E8893 11/01/05 11/01/06 EACH OCCURRENCE s2,000,000 —X1 OCCUR CLAIMS MADE AGGREGATE _ s2,000,000 $ $ XIDEDUCTIBLE RETENTION $ 10 000 B WORKERS COMPENSATION AND 2093950 10/01/05 10/01/06 X WC STATU- OTH- EMPLOYERS' LIABILITY ANY PROPRIETOR/PARTNERIEXECUTIVE E.L. EACH ACCIDENT $500 000 E.L. DISEASE - EA EMPLOYEE s500,000 OFFICER/MEMBER EXCLUDED? Des, describe under SPECIAL PROVISIONS below E.L. DISEASE - POLICY LIMIT $500,000 OTHER DESCRIPTION OF OPERATIONS I LOCATIONS / VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT / SPECIAL PROVISIONS Project Description: Ziegler Road Widening Bid Number: 5834 The following are Additional Insureds as respects General Liability only (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 ,�0* 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 AGOKD 25 (ZU01/08) 1 of 3 #M271146 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. ACORD 25-S (2001108) 2 of 3 #M271146 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 #M271146 COMMERCIAL GENERAL LIABILITY THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY BLANKET ADDITIONAL INSURED (CONTRACTORS) 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. c) This insurance does not apply to "bodily in- jury" or "property damage" caused by "your work" included in the "products -completed operations hazard" unless you are required to provide such coverage for the additional in- sured by a written contract or written agree- ment in effect during this policy period and signed and executed by you prior to the loss for which coverage is sought and then only for the period of time required by such con- tract or agreement and in no event beyond the expiration date of the policy. 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. 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: 1. The preparing, approving or failing to prepare or approve maps, shop drawings, opinions, reports, surveys, field orders, 5 change orders, or drawings and specifi- cations; and 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 unless 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 specifically requires that this insurance apply on a primary or non-contributory basis. When this in- surance is primary and there is other insurance available to the additional insured from any source, we will share with that other insurance by the method described in the policy. As a condition of coverage, each additional insured must: II. Supervisory or inspection activities per- a.) Give us prompt written notice of any "occur - formed as part of any related architectural rence" or offense which may result in a claim or engineering activities. and prompt written notice of "suit". CG 1�2 46 10 02 Copyright, The Travelers Indernnity Company, 2002 Page 1 of 2