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Home My WebLink About374454 ARTHUR J GALLAGHER RISK MGT SERVICES - INSURANCE CERTIFICATE (3)PCE APPLICATION I COMMERCIAL IN?URA -AACDIRQ- APPLICANT INFORMAT ON SE TION DATE OS/12/2006 PRODUCERNVC jExtr(303)773-9999 CARRIER N A I C C 0 D E : UNDERWRITER FAX (36b7 97-76' . . I .. . . . . ....... I .... .. Arthur 3. Gallagher Risk Management Servii POLICIES OR PROGRAM REQUESTED 6399 S. Fiddlers Green Circle Suite 200 Greenwood Village, CO 80111 INDICATE SECTIONS ATTACHED EQUIPMENT FLOATER ....... ..................... GARAGE AND DEALERS 'PROPERTY X q INSTALLATIOWBUIUDERS RISK VEHICLE SCHEDULE GLASS AND SIGN ELECTRONIC DATA PROC BOILER & MACHINERY .. ....................... ............ .......... CODE; SUB CODE: ... ....... ACCOUNTS RECEIVABLE; COMMERCIAL VALUABLE PAPERS GENERAL LIABILITY WORKERS COMPENSATION AGENCY CUSTOMER ID CRIME/MISCELLANEOUS CRIME BUSINESS AUTO UMBRELLA 00001271 TRANSPORTATION/ ., TRUCKERSIMOTOR CARRIER ...... MOTORTRUCK U 1A I 1J* Ur ZsUbMIZOONJIN rAtvKAtjr rVLK;Y INI-UKIMIA I [UN QUOTE ISSUE POLICY ENTER THIS INFORMATION AMEN COMMON DATES AND TERMSAPPLYTO SEVERAL LINES, OR FOR MONOLINE POLICIES. ... .. ..... . . .......... ... .... . ....... I ........ ... . 1—I.— ....... BOUND (Give Date and/or Attach Copy): PROPOSEDEFFDATE : PROPOSeDEXPDATE BILLINGPLAN PAYMENT PLAN AUDIT : ............... ...... - ...... ....... ................ ............. .................. ........................... ....... -... DATE TIME AM DIRECT BILL 06/01/2006 06/01/2007 r PM AGENCY BILL NAME (Fint Named insured & Other Named Insureds ) ; MIN UKbUUolftcg uuu-uu-uuou (qf First Named Insured)i ;MAILING ADDRESS INCLZIP+4 (of Fint Named Insunid) Larimer City of Fort Collins PHONE. 0-7-6) 2,21 -4-7-14— .... ** .... ........ . ... ..... P.O. Box 580 .Fort Collins, CO 90522 .......... . .... .. ... . .......... S66&AJPJR.5' :NOTFOR CR BUREAU ID NUMBER Y INDIVIDUAL CORPORATION :CORPORATION NAME SEAR 6U$ STARTED 1 PARTNERSHIPJOINT VENTURE ......LIMITED b .40APORATION Ot her INSPECTION CONTACT Pi I ick ACCOUNTING . . . . i I R I EC OR I DS .. CO I NT . ACT P I H 1 0 1 N . E .. .......... .......... .............................. ..(A!P.No. Ext)-t ............. ....... ..... ... LOC # i BLO 0 STREET CITY, COUNTY, STATEVP+4 CITY LIMITS INTEREST YR BUILT PARTOCCUPIED INSIDE OWNER OUTSIDE TENANT INSIDE ............. .. ....... j ...................... ........... . ... .... —... OWNER OUTSIDE TENANT 'INSIDE . ....... .. .. OWNER OUTSIDE :TENANT 4.A19 9XI�LoJUN LY �-VRESPONSES___,...,.._ ... 1..,... - .. ...... ......... .... . ....... . ........... ........ ........ No 1. IS THE APPLICANT A SUBSIDIARY OF ANOTHER ENTITY OR DOES -yes. 7. ANY PAST LOSSES OR CLAIMS RELATING TO SEXUAL ABUSE OR ...... TFtEAPPJJCANT�4iAVE.ANXSUBSIDLARIE$7 ............ ...... ........ ..... ..... ...... ... ........................ .... ..k4OLESTATAONALLEGA.TIQNS,DISCFtIMIUATIONOR.NEGUGENT.HiRiNG2+...... 2—.ISA.FPRMAI.SAFFTYPR.0QRAM INOPeRATtQN?_ .. S. DURING THE LAST TEN YEARS, HAS ANY APPLICANT BEEN CONVICTED ... OF ANY DEGREE OF THE CRIME OF ARSON? (in RI, this question must be PC .F.�A.MM 8 J_ANYEX S Rg.Tp .A an�sd by any applicant For properly insurance- Faikve to disclose the existence of an anson com,iction is a misdameartar punishable by a A.. ANY. CATASTROPHE EXPOSURE? ......... ............. .. ........ one y"m 91 imprivonnignt . ..... . .. ....... UBMITTED? ....... 9.,jr. PE.Y10. ON ,p . I$? Y..VNr .40f.ftO ..J.�Qfl.E 6. ANY POLICY OR COVERAGE DECLINED CANCELLED OR NON-RENEWEDa .. DURING THE PRIOR3 YEARS? NOT AROLICABLE, IN NO + to ANY BANKRUPTCIES TAX OR CREDIT LIE IN THE PAST 5 YEAR§7 LIENS SAGAINST. I . THE . . A P . PLI I C I A . NT 1.1-1- REMARKS ACORD 125 (7/98) D PLEASE COMPLETE RFVFRSF.cunF y [a (9) ACORD CORPORATION 1AA3 ..4� s:n 111 ,:.%,�, `a;.. „.,.• 'KIN �;.. :ft tiy` DATE MMro fYY 05/12/2006 CORD@ PRODUCER` PHONE :.;' APPLICANT C303)773-9999 FAX (303)773-9776 City of. Fort Collins n"s PROPOSED EFF. DATE PROPOSED EXP. DATE BILLING PLAN PAYMENT PLAN PREM. ADJ. ...... ... ............... .. ..... .:.. ........- .. . .. ...._. .. Arthur 1. Gallagher Risk Management Seri: 06/01/2006 06j01j2007 AGENCY 6399 S. Fiddlers Green Circle DIRECT Suite ZOO ;„•; FOR COMPANY USE ONLV.......... ...... .._.............. __........ .......... :............... ........................ ......... .... .........:..,.............. Greenwood Village, CO 80111 -x- •y }s.r :[ [e.t:�:s;i.::.. rr<}x`^'s 3' s3\ a.M <,. .a.. R\::.<rs\t•2:..;.NN,, ....:.a. .. .. :x.;as: v i t4¢i Q}f':.;avia'� ci _yi,� ?� r,� �u . E 3e a.� �jir;L:.� ?;� 33Fi.\}t :6'�<..^,',`�J.i\ • 2 ..\3\t t'i.•. - »i; a:�a.•`�:Xa:�,.} i ,..:. t CS alcGS "f _. '. i:' rc� fi J � :�� 3 j,� T � h:i.ry T. i� Cx� � •�`•� \,•:` •``�4.,f5:v €h. r, � i'nj.: C.< Fa c.•��.•k•°tr %t• ei' t`2§�'ra{ � �'� z<,� i i ); �y$in ,'M�a gm �' Q `�\$,�{`\k,:. r \tiq,� .C+�'�� .a..;... .. > 5....,:..a,X Y _: -. ' at "#. '•{:; : �; P £: f`C i ✓ t } ; 3 #�£ ? : } :�:3° . '� % _ �5� .�.'`.' . . is ' ^�oY.t:�ms>:wt`�'2a`Y�`iq'.�w€0 e $ .. .:-., n..:..:.:....5:: ..:.a.. .. >.,.::.. ._.. � � �. A.•-:; n.,n4.v..,iM"n, :vr.kmm�.,..n::l..S:i .Y}:f•..l'C:n,n:.tii :Lmm,n»[C:n ,...n..w:`n��J :a,�tii?•( : }„ ••i: :.C},a:.a.: ... .,n, ._:.......... ..... ..iry e....., ivn. v ..n..,n.: Y n .:.............. }. LIMIT AT ANY SINGLE LIMIT PER UMITATATEMPORARY TRANSIT '" CAUSES OF LOSS SUB LIMIT DEDUCTIBLE fF LOCATION DISASTER LOCATION LIMIT "%'•"• - :EARTHQUAKE S FLOOD S .._. <.... .... .... ....... SPECIAL :BROAD BASIC �" ... .... .>. .n .., ,. .... .�.Fi.. u:... i.3.>. A. yvCa[>.Y.Y.u...$n:.w.:..1:.2{5}:Sn;••\'J...k:.: ...t ....)..0.., [P:.. ... .i .�:\ ii i°bi :f vfL$:irv$:f {wSTHV.`"wv '•:al':'n n}.. .5 :. CppKK..� yyyy. yy. .: aar.. .:., ...af.. $. ,:.. xrc.:ia:.. :..q[,.Y+.. .... .[s. .:.{n. i.. ..SI. a..fa ...,�,�;� f:r t5:::"ti. ':2:f[i'S. :!K•: `. . 8..i;. �L' E V [ � );, 5{. ),:..,, •, ... \` .... .a .,. .4.. rFY -. x.7:'f•..o.t. ..fi�- Yv:. ...f„ ,........ r.....i A . .: ...... .. ...: .:fi` .. $i .. �. ,�:..r..�,. SPECIFY THE APPLICANTS OPERATING TERRITORY: '•'ENTER THE GROSS INSTALLATION RECEIPTS. .............._. ... ...... . ........... .. .`. _.. .._...' "< PAST 12 MONTHS NEXT 12 MONTHS ESTIMATE ........................................................i......................... _.............. _....- E]�'J!M')u�UFLSv.,a i,.i i 2 f^.t _.5. 2 r5,� ci s t•,_}rf t� Lf <'. rir .: .. ...: .. `.S .....: .. .... :.:$ .. ,A :.. 'i'. .n .r'� C.: l ,. .. , .:. ,nC ., , nv.�N. v $ e,.n.n n,., \ .,, ANNUAL ' M JOBS IN PROGRESS i COST OR VALUE OF EACH INSTALLATION TYPE NUMBER OURATFON"""' ........ ... ... ._ ... ...... ...... .... .. MATERIAL COST (% of Total) MAXIMUM : AVERAGE : MAXIMUM MINIMUM AVERAGE RESIDENTIAL f 1 $ S % COMMERCIAL % F 2�,� 1�SAA��. SF {F�1^ilf�,TR x'I F4 >Ai ?`{C2� it,:..z w�f� 3 �I fSi •xt� �¢ }Yy,.,Kfib� �i�f¢Y �CPSx ,tY xh}�t .2S .ak�aF�'t`kF35.xK^.,:i�� i,2X�`r��,�,3,:: �A:. )t, :`.�'. NAME 6 ADDRESS NAME R ADDRESS _. INTEREST .INTEREST CERTIFICATION CERTIFICATION REQUIRED REQUIRED NAME ...... ...... ............._ ............... ............. ..... _J... ........ .... ......._. ...... ......._. ........._...... ;._... ..... ............ 8 ADDRESS - NAME S ADDRESS INTEREST :INTEREST - C REQUREDON CERTIFICATION REQUIRED '<.)".: .! ', rva. .... ,...aL.k.ia.,}: $:.„•:t}:•t,,..t}xl, .t ,.. ). ,.. ..... .. ...S:Si})'::".>':}:5::':i:�.. : .;:,.. ....,.. R;.. ..:...:,:.:::::,:. .. .4 :..:): i.+.;. .. :.....6r..:+�5'r�}x.... .,..: i.:.: }.: ..i. :S:f:.:.,?f. 5`S::u'::^,. '. :.»-•2, a' mu: . .,.....,ff...-.-.. .nf,.., �r.�}.%w?...,,..��.r:.Y:.[„tior,[.Y.:�'.w>3..r.,:m.r�,.rvn3,,.,. n;..w.ivnb�:r ,.vn ira ..n)..rv:. ,.. fsF; �� Y i FF.. ;t:2Lx+�.•�� i��:.<. DESCRIBE ALL HOISTING OR OTHER OPERATIONS REQUIRING RIGGING. r•ESTIMATE % VALUE OF MATERIAL SHIPPED TO JOB i' SITE AT APPLICANTS RISK. % I<: DESCRIBE JOB SITE SECURITY x, REMARKS �C"+L1�1i#`�� Y\'.[ :.. t.}',ts.�5`�)�'1`�e"a5i�f.#?�`��,<`�xl�«' ,i.<i �f , ..:ic ?.:.).'.:;��.31?�:C+>1312F1•QF,i1�4'•'Fls�,i�[�$.lil�`, . ... ... ... ..... . ... ... .... .............. rg Xg.g ....... Nii M g:M= X��,,. .:n *9 M.� 2'. 1 ... W UNIT ATA TEMPORARY CAUSESOFLOSS SUB LIMIT DEDUCTIBLE LIMIT AT LOCATION TRANSIT LIMIT ....... ........ LOCATION ........... EARTHQUAKE .. .... N/A FLOOD :$ N/A 17,733,658 s N/As N/A SPECIAL .......... BROAD BASIC P MN' Y. in.4 AW MR, EF VALUE JOB TERM OF OWNER DESCRIBE JOB SITE SECURITY .......... CONTRACT AMOUNT SUPPLIED PROPERTY Construction fencing around COMMENCEMENT COMPLETION ........................ ...... I .. .......... ......... ............. ...... .. ..... ........... ...... ..................................... .. entire facility, locked at 6/6/06 8/1/07 = 21,631,167 0 night and lighting. ...... ........... .............. K DESCRIBE THE WORK TO BE PERFORMED (Indu0V Location ACORD 125) Construction of a new police station.- 99,878 square feet, steel frame and concrete construction. INSURED'S JOB NUMBER: 30516300 .......... ....................... .... ........ W. MAN Rim" MEN, � 11 Tinll. NAME & ADDRESS NAME& ADDRESS 13 The Neenan Co. US Bank National Association 2620 E. Prospect Rd., Suite 100 950 17th St., Suite 300 Fort Collins, CO 80525 Denver, CO 80202 ......... .. ........... ..... ...... I .......... .... .... ... ..... . .. .... ................... .... ....... .. . . . .... .............. INTEREST � INTEREST CERTIFICATION Design/Builder CERTIFICATION X REQUIRED Financer x REQUIRED NAM E & A D D R ES S .......................... .... INTEREST CERTIFICATION REQUIRED CERTIFICATION REQUIRED M r. MR N 0 M.P"S TOTAL VALUES TO BE SHIPPED TO THIS JOB SITE ATAPPLICANT'S RISK DESCRIBE ALL HOISTING OR OPERATIONS REQUIRING RIGGING. AMOUNT SHIPPED % FOR APPLICANTS % BY COMMON/ VEHICLES CONTRACT CARRIER DISTANCE INVOLVED %: REMARKS AN) ........... . M044% 1'. 095, ..... . . 00,00 m ...f. .. PON', "iR .. ..