HomeMy WebLinkAbout103265 HAISTON OIL COMPANY INC - INSURANCE CERTIFICATE (9)CERTIFICATE OF INSURANCE
ISSUED BY
ASSOCIATION INSURANCE MARKETING, INC.
PO BOX 68, EVERGREEN, CO 80437.0069
FAX 303 674 8819
303 674 86851800 5718685
Insured:
HAISTON OIL CO, INC.
P.O. BOX 1576
FORT COLLINS, CO 80522
TO WHOM IT CONCERNS:
Company Affording Coverage
PINNACOL ASSURANCE
7501 EAST LOWRY BLVD.
DENVER, CO 80230 (303 361 4000)
This is to certify that PINNACOL ASSURANCE has issued a Standard Workers' Compensation and Employers'
Liability Policy as described below covering the liability unposed upon subject employers by the Workers'
Compensation Act of Colorado, said policy being in good standing as of this certificate issue date: 01-09-06.
POLICY NUMBER: 3019023 BROKER OF RECORD: BROKER CODE NUMBER G30166
POLICY PERIOD: 02-01-06 to 02-01-07 ASSOCIATION INSURANCE MARKETING, INC.
CLASSIFICATION: GASOLINE DEALER & D PO BOX 68
CODE: 8350 EVERGREEN, CO 80437-0068
LIMITS OF LIABILITY
EMPLOYERS' LIABILITY COVERAGE Part Two of the policy, LIMIT OF EMPLOYERS LIABILITY, is as follows:
Bodily Injury by Accident $ 500,000 each accident
Bodily Injury by Disease $ 500,000 each employee
Bodily Injury by Disease $ 500,000 policy limit
IMPORTANT: THE COVERAGE DESCRIBED ABOVE IS IN EFFECT AS OF THE ISSUE DATE OF THIS CERTIFICATE. IT IS SUBJECT TO
CHANGE AT ANY TIME IN THE FUTURE.
CANCELLATION
SHOULD THE ABOVE DESCRIBED POLICY BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, PINNACOL ASSURANCE
WILL ENDEAVOR TO MAIL 10 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER, BUT FAILURE TO MAIL SUCH NOTICE SHALL
IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON PINNACOL ASSURANCE OR ASSOCIATION INSURANCE MARKETING.
SPECIAL CONDITIONS:
CERTIFICATE HOLDER
CITY OF FORT COLLINS
ATTN: JIM IUME
P.O. BOX 580
FORT COLLINS, CO 80522
ft I ••
-�rlaacG;gz�