HomeMy WebLinkAboutRESPONSE - BID - 5964 HAULINGBID SCHEDULE 5964 Hauling
You may attach a separate page with an equipment list-- Please include Firm name on it.
EQUIPMENT
YR
MAKE
MODEL
CY.YDS.
HP
$/HR.
TRACTOR/TRL
$
TRUCKS
$
TANDEM DUMP TRUCKS
2
W,,,cl<
5 WOL
la
40O
$ qi?. Qb
$
TANDEM DUMP TRUCKS 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 �I T'S Tr )t Vi n Q
Are you a Corporation; Partnership. DBA, LLC, or PC
SIGNATURE
PRINT NAME se-n
ADDRESS v?al W. -bou245 oU -* /7
f d Y r (� 1�1►1 5� �Jr-Z I
PHONE j 70- aai-YOOF
CELL PHONE f 20-6F1 `%�53/2
FAX /C%Q" yffj'- 3a1/
EMAIL N�/%'
5
SA January 2005
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
❑ STATE FARM INDEMNITY COMPANY of Bloomington, Illinois, or
❑ STATE FARM GUARANTY INSURANCE COMPANY of Bloomington, Illinois
has coverage in force for the following Named Insured as shown below:
NAMED INSURED: PFLIPSEN, STAN dba JJ'S
TRUCKING
ADDRESS OF NAMED INSURED: 221 W DOUGLAS
RD #17,
FORT COLLINS
CO 60524
POLICY NUMBER
S55 8277-E16-06P
EFFECTIVE DATE
OF POLICY
11/16/05-05/16/06
DESCRIPTION OF
1972 MACK DUMP
TRUCK
VEHICLE (including VIN)
R5711LS12978
LIABILITY COVERAGE
E YES ❑ NO
❑ YES
❑ NO
❑ YES
❑ NO
❑ YES
❑ NO
LIMITS OF LIABILITY
a. Bodily Injury
Each Person
$1, 000, 000
Each Accident
$1, 000, 000
b. Property Damage
Each Accident
$1, 000, 000
c. Bodily Injury &
Property Damage
Single Limit
Each Accident
$1, 000, 000
PHYSICAL DAMAGE
COVERAGES
E YES ❑ NO
❑ YES
❑ NO
❑ YES
❑ NO
[]YES
❑ NO
a. Comprehensive
$ 500 Deductible
$
Deductible
$
Deductible
$
Deductible
❑ YES ENO
[I YES
❑ NO
❑ YES
❑ NO
❑ YES
[INO
b. Collision
$ Deductible
$
Deductible
$
Deductible
$
Deductible
EMPLOYERS NONOWNED
CAR LIABILITY COVERAGE
❑ YES E NO
❑ YES
❑ NO
❑ YES
❑ NO
❑ YES
❑ NO
HIRCOVE GECAR LWBILITY
❑ YES E NO
❑ YES
❑ NO
❑ YES
❑ NO
❑ YES
❑ NO
FLEET - COVERAGE FOR
MOTORCENSED
HIICLESS
❑ YES E NO
❑ YES
❑ NO
❑ YES
❑ NO
❑ YES
❑ NO
Licensed
1680
03/09/0
`nature of AOthdfi3"ed Represedtative' Title Agent's Code Number Date
-St
and Address of Certificate Holder Name and Address of Aaent
CITY OF FORT COLLINS
DIRECTOR OF PURCHASING
PO BOX 580
FORT COLLINS CO 80522
6 RISK MANAGEMENT
CRAMER STATE FARM
GARY CRAMER
1275 E MAGNOLIA ST. #I
FORT COLLINS CO 80524
INTERNAL STATE FARM USE ONLY: ❑ Request permanent Certificate of Insurance for liability coverage.
122429.3 Rev. 07.26.2005 -�'Request Certificate Holder to be added as an Addftional Insured.
ACERTIFICATE 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
❑ STATE FARM INDEMNITY COMPANY of Bloomington, Illinois, or
❑ STATE FARM GUARANTY INSURANCE COMPANY of Bloomington, Illinois
has coverage in force for the following Named Insured as shown below:
NAMEDINSURED: PFLIPSEN, STAN dba JJ'S
TRUCKING
ADDRESS OF NAMED INSURED: 221 W DOUGLAS
RD #17,
FORT COLLINS CO
80524
POLICY NUMBER
S55 8277-E16-06P
EFFECTIVE DATE
OF POLICY
11/16/05-05/16/06
DESCRIPTION OF
1972 MACK DUMP
TRUCK
VEHICLE (Including VIN)
R5711LS12978
LIABILITY COVERAGE
® YES ❑ NO
❑ YES
❑ NO
❑ YES
❑ NO
❑ YES
❑ NO
LIMITS OF LIABILITY
a. Bodily Injury
Each Person
$1,000,000
Each Accident
$1,000,000
b. Property Damage
Each Accident
$1,000,000
c. Bodily Injury &
Property Damage
Single Limit
Each Accident
$1,000,000
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
$ Deductible
$
Deductible
$
Deductible
$
Deductible
EMPLOYERS-0WND CO
CAR LIABILITYCOVERAGGE
[I YES ®NO
❑ YES
❑ NO
❑ YES
❑ NO
❑ YES
El NO
COVERAGE
OVERAGE
❑ YES ® NO
El
❑ YES
❑ NO
❑ YES
❑ NO
❑ YES
❑ NO
FLEET - COVERAGE FOR
ANDUCENSED
MOTORVEHICLES❑
YES ® NO
❑ YES
❑ NO
❑ YES
❑ NO
❑ YES
❑ NO
CITY OF FORT COLLINS
DIRECTOR OF PURCHASING &
PO BOX 580
FORT COLLINS CO 80522
Holder
RISK MANAGEMENT
Licensed
Title
and
1680
CRAMER STATE FARM
GARY CRAMER
1275 E MAGNOLIA ST. #I
FORT COLLINS CO 80524
INTERNAL STATE FARM USE ONLY: ❑ Request permanent Certificate of Insurance for liability coverage.
122429.3 Rev. 07-26-2005 ❑ Request Certificate Holder to be added as an Additional Insured.
03/09/06