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HomeMy WebLinkAbout130163 EMPIRE CARPENTRY - INSURANCE CERTIFICATE (3)CERTIFICATE OF LIABILITY INSURANCE American Family In5urance Company ❑ American Family Mutual Insurance Company if selection box is not checked. 0000 American Pky Madison, Wisconsin 53783-0001 Agent a Name, Address and Phone Number (Agt./Dist) Insured's Name and Address: Larry D Peterson (119/309) Empire Carpentry LLC 149 W Harvard, Suite102 PO Box 245 Fort Collins„ CO 80525 Bellvue, CO 80512.0245 970-229-9393 This certificate Is Issued as a matter of information only and confers no rights upon the Certificate Holder - This cardflcate does not amend. extend or after the coverage afforded by the oollcles listed below. �J 5' l'qh .F', ., �h .. b', . ,� •�.d is u � �(., ,:i �SrO . �.�> This is to certify that 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 lolicies. POLICY TYPE TYPE OF INSURANCE POLICY NUMBER LIMITS OF LIABILITY Effective Expiration Mo,Da ,Yr Mo Da Yr Homeowners/ Bodily Injury and Property Damage Mobilshomeowners Liability Each Occurrence Boatowners Liability Badly Injury and Property Damage Each Occurrence Personal Umbrella Liability Bodily Injury and Property Damage Each Occurrence Farm/Ranch Liability Farm & Personal Liability Each Occurrence Farm, Employees Uabili Ewt1 Occurrence Statutory + + + Workers Compensation and Each Accident Employers Liability + Disease - Each Employee Disease - Policy Limit General Liability General Aggregate $ 2,000,000 ® Commarrial General 05-X16M3-14 10/30/2005 10/30/2006 Products - Completed Operations Aggregate $ 2.000,000 Uablllty (occurrence) Personal and Advertising Injury $ 1,000,000 © Each Occurrence $ 1,000,000 0 Klrs Damage (Any One Fire) $ 100,000 Medical Expense (Any One Person $ 5,000 Businessowners Liability Each Occurrence + + Aparegate + + Automobile Uabtllty Bodily Injury - Each Person $100.000 ® Owned Autos (Basic form) 05-X90782-02 09/01/2006 09/01/2006 Bodily Injury • Each Accident $1100.000 ❑ Owned Autos (Comp form) Property Damage $100.000 ❑ Hired Autos Bodily injury & Property Damage Combined ❑ Non -owned Autos ❑ Garage liability Excess Liability -T-1 ❑ commercial Bisinket Excess Each Occurrence/Aggregate DESCRIPTION OF OPERATIONSILOCATIONS/YEHICLES/AF-STRICTIONS/SPECIAL ITEMS r The individual or partners shown as Insured "" elected to be The City of Fort Collins Department of Purohesing Is listed as an additional insured. covered as employees under this policy. ++ Products-oompleted Operations aggregate is equal to each occur ,,- limit and Is Included in lic r ate. ® should any of the above described policies be canceled before the ADDt110NAL INSURED expiration date thereof, the company will endeavor to mail `(10 days) written City of Fort Collins notice to the Certificate Holder named, but failure to mail such notice shall Dept of Purchasing impose no obligation or liability of any kind upon the company, its agents or Po Box $00 representatives. -t0 days unless different number of days shown. Fort Collins, CO 80522 D This esrdfles coverage on the date of Issue only. The above described Fax: 221-6707 policies are subject to cancellation in conformity with their terms and by the Alin: John Stevens laws of the state of Issue. DATE ISSUED AUTHORIZED REPRESENTATIVE 11 /23/2005 C— U-201 Ed.1/96 ORIGINAL - Certificate Holder, COPIES to Services, Insured, Agent Stock No. 06668 10/10 39Vd NOSd313d A66V-1 WtldWV L8066ZZOL6 bE:60 900Z/EZ/TT 11/23/2005 12:06PM Pinnacol Assurance PAGE 2 OF 3 ACORD CERTIFICATE OF LIABILITY INSURANCE ATE 11101/D2005 PRODUCER P1Tmacol Assurance 7501 E Lowry Blvd DENVER CO 90230-7006 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. INSURERS AFFORDING COVERAGE NAIC # INSURED EMPIRE CARPENTRY LLC 521.5 SYCAMORE ST FORT COLLINS CO 80521 INISURERA: Finnacol Assurance 41190 INSURE IZ ma rseR c: mwRve D: INa1RaRE: 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. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. TIER LTR ADm DJSRD TYPE OF INSURANCE POLICY NUMBER P ICYRPPECTNE DA MA H TCYEIHRAmw DATE(MMMDAYM LIMNS W NHRAL UUMTIY COMD.ERCIAL GENERAL LMHILTTY CLAIMS MADE 11 OCCUR EACH OCCURRENCE DAMAWTOYA04M PREMISES , . MSD9" PTDISONAL a ADv E;Aw GEN•L AGGREGATE LIMIT APA.ERS PER: AOLICY CT LOC GRNERAL ACGREGTE r PRODUCTS. OOMP"AGG AUTOMOHLL1110TLlTY ANYAUTO ALL OWNED AUTOS SCHMMSDAUTO6 HIRED AUTOS NON OWNED AUTOS COMBINED MINGLE LIMB 99R1N�1 SODLLYINDRY ea _ BCOLLYINREY PROPRRIYDAMACE aadC9n GARAGE LIARMTTY ANVAUTO AUTOONLY -RA ACCIDENT OIRERTHAN EAACC AUTOONLY: ACC R%C1S&USB1E.LA 1 MilaTM OCCUR CLAIMSMADE DEDUCTIBLE RHIENDON S SACK OCCURRENCE ACCRECATE A WORKERS COMPENSATION AND EMPLOYERS LTAHD. ANY PROPRETO"ARTNERTMCLMM CPTICER/ABMBRRE%CLUDED? Sm. jd.Gi[eu 1519590 09/01/20D5 09/Ol/2D06 NJ WCSTATU- OTHER TCRV LIM E.L. EACHACCMEN`r $100 000 E.L. DISEASE RA $1D0000 E.L.DISEASE MUCYLO40T S5D00D0 OTHER DSSLRDTION OF OPERATIONS / LOGTtONS / V8II1T.188 /E%CLTSIONS ADDID eY BNDORSSMENT / SPICIAL PROVISIONS . SEE BACK OF CERTIFICATE FOR CLASS COVERAGE AND OWNERSHIP COVERAGE DETAIL CERTIFICATE HOLDER CANCELLATION $70003 - CITY OF FORT COLLINS PURCHASING DEPARTMENT ATTN: JOHN STEVENS PO BOX 580 FORT COLLINS CO 80522-0580 ACORD 25 2001/0 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING COMPANY WILL ENDEAVOR TO MAIL 0 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE COMPANY ITS AGENTS OR REPRESENTATIVES. AUTHORIZED REPRESENTATIVE Nichole Valdez Underwriter ACORD CORPORATION 1888 SMMHKTCSRSpp 13MIM 11:M:M 15126M U~ 1VJ1119B11:" UW1M 11/23/2005 12:06PM Pinnacol Assurance CERTIFICATE HOLDER COPY PAGE 3 OF 3 CITY OF FORT COLLINS PURCHASING DEPARTMENT ATTN: IOHN STEVENS PO BOX 580 FORT COLLINS CO 80522-0580 POLICY NUMBER: 1519590 BUSINESS LOCATION: EMPIRE CARPENTRY LLC CLASSIFICATION OF OPERATION CLASS DESCRIPTION IMPORTANT If the certificate holder Is an ADDfI'IONAL INSURED, the pollcy0w) must he endorsed. A statement on this certificate does not confer rights to the certificate holder In lieu of such endorsement(s). If SUBROCAT[ON IS WAIVED, subject to the terms and conditions of the paltry, ceMan pollclm may regnlre an endorsement. A statement an this certificate does not confer rights to the certificate holder in 11w of such endomemem(s). DISCLAIMER The Certificate of Insurance an the reverse side of this farm dam not constitute a contract between the Issuing msurer(a), authorized representative m producer, and the certificate holder, nor dam it affirmatively or negatively amend, extend or site the coverage afforded by the policies listed thereon. COVERAGE COVERAGE RATING EFFECTIVE EXPIRES TYPE 564505 CARPENTRY -RESIDENTIAL 09/01/2005 09/01/2006 EM