HomeMy WebLinkAboutRESPONSE - BID - 5964 HAULINGBID SCHEDULE 5964 Hauling
You may attach a separate page with an equipment list— Please include Firm name on it.
r � ♦ it
�,7�
� �
��
,
TANDEM DUMP TRUC KS W/PUP
OTHER EQUIP (LIST TYPE)
Failure to provide said equipment with qualified drivers as listed in the bid submitted may result in the
removal of the vendor's name from the City's bidding list for a period of three years.
FIRM NAME -N
Are you a Corporation, P nershi DB LLC, or PC
SIGNATI IRE . h. L
PRINT NAME
ADDRESS , "�I �C o V� ej s �011--
v
VA: co g)s--)g- l-2�y
PHONE
CELL PHONE I)d -S,-(,r) ' I -)�Z{a,
FAX
EMAIL _
SA January 2005
A
CERTIFICATE OF INSURANCE
SUCH INSURANCE AS RESPECTS THE INTEREST OF THE CERTIFICATE HOLDER NAMED BELOW WILL NOT BE
CANCELED OR OTHERWISE TERMINATED WITHOUT GIVING 10 DAYS PRIOR WRITTEN NOTICE TO THE
CERTIFICATE HOLDER, BUT IN NO EVENT SHALL THIS CERTIFICATE BE VALID MORE THAN 30 DAYS FROM
THE DATE WRITTEN. THIS CERTIFICATE OF INSURANCE DOES NOT CHANGE THE COVERAGE PROVIDED BY
ANY POLICY DESCRIBED BELOW.
This certifies that: ❑ STATE FARM MUTUAL AUTOMOBILE INSURANCE COMPANY of Bloomington, Illinois
® STATE FARM FIRE AND CASUALTY COMPANY of Bloomington, Illinois
❑ STATE FARM COUNTY MUTUAL INSURANCE COMPANY OF TEXAS of Dallas, Texas, or
❑ STATE FARM INDEMNITY COMPANY of Bloomington, Illinois
has coveraae in force for the following Named Insured as shown below:
NAMED INSURED: Edwards, Roy
ADDRESS OF NAMED INSURED: 7325 S Shields St Fort Collins,
CO 80526-9614
POLICY NUMBER
113 7925-A18-06A
EFFECTIVE DATE
OF POLICY
02-09-2006
08-09-2006
DESCRIPTION OF
VEHICLE (Including VIN)
1986 Kenworth
W900 Dump Truck
LIABILITY COVERAGE
® YES
❑ NO
❑ YES
❑ NO
❑ YES
❑ NO
❑ YES
❑ NO
LIMITS OF LIABILITY
a. Bodily Injury
Each Person
500
Each Accident
500
b. Property Damage
Each Accident
500
c. Bodily Injury &
Property Damage
Single Limit
Each Accident
PHYSICAL DAMAGE
COVERAGES
® YES
❑ NO
❑ YES
❑ NO
❑ YES
❑ NO
[]YES
❑ NO
a. Comprehensive
$ 500
Deductible
$
Deductible
$
Deductible
$
Deductible
® YES
❑ NO
❑ YES
❑ NO
❑ YES
❑ NO
❑ YES
[]NO
b. Collision
$ 500
Deductible
$
Deductible
$
Deductible
$
Deductible
SCAR LIABILITY COVERAGE
❑ YES
❑ NO
❑ YES
❑ NO
❑ YES
❑ NO
❑ YES
❑ NO
HIRED RLIABILITY
COVERAGE
❑ YES
❑ NO
❑ YES
❑ NO
❑ YES
❑ NO
❑ YES
❑ NO
FLEET - COVERAGE FOR
MOTORALLOWNEDNDUCENSED
H/ IICLLES
❑ YES
❑ NO
❑ YES
❑ NO
❑ YES
❑ NO
❑ YES
❑ NO
15A s
Purchasing Department
215 N. Mason
Fort Collins, CO 80524
06-1622 03-13-2006
Title
State Farm Insur
John K. Martinez
2601 S. Lemay Ave Suite 17
Fort Collins, CO 80526
INTERNAL STATE FARM USE ONLY: Request permanent Certificate of Insurance for liability coverage.
122429.2 Rev. 0e-10.2004 F1 Request Certificate Holder to be added as an Additional Insured.
uate