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Home My WebLink AboutGALLAGHER - INSURANCE CERTIFICATE2EQ COMMERCIAL INSURANCE -AM - APPLICANT INFORMATION SE APPLICATION TION I DATE OS/12/2006 PRODUCER ( CARRIER C0E: UNDERWRITER FAX .. . . .. . . . ............... . Arthur J. Gallagher Risk Management Servio POLICIES OR PROGRAM REQUESTED 6399 S. Fiddlers Green Circle Suite 200 INDICATE SEC . T ION 6 ATTACHED T A CHED EQUIPMENT U IP MENT FLOATER . R . . . I . I GARAGE . . AND I - DEALERS Greenwood Village, CO 80111 1 ...... X. I PROPERTY INSTALLATIONIBUILDERS RISK VEHICLE SCHEDULE GLASS AND SIGN ELECTRONIC DATA PROC BOILER MACHINERY .................................. ..... ............ ... ... .............. .......... . SUB CODE: CODE: . 4 ........... . . .. .. ... . ACCOUNTS RECEIVABLE1 COMMERCIAL VALUABLE PAPERS GENERAL LIABILITY WORKERS COMPENSATION AGIEENCY66STOMERID CRIMEIMISCIELLANEOUS CRIME BUSINESS AUTO UMBRELLA 1 00001271 TRANSPORTATION! MOTOR TRUCK'OCARGO TRUCKERSNOTOR CARRIER SI AI Llb Vt- bUbMitibIVN rA6rAtJ= rVI1t6T imruKiwA I ivim QUOTE ISSUE POLICY ENTER THIS INFORMATION WHEN COMMON DATES AND TERMS APPLY TO SEVERAL LINES, OR FOR MONOLINE POLICIES. .1.. . . ... .. I ...... ..... ..................... .... - BOUND (Give Date andfor Attach Copy): PROPOSED PROPOSED BILLING PLAN PAYMENT PLAN a : AUDIT ........ .......... ........ ............................................ ............ ................ ..... ........... ...... I .. ....... I ...................... DATE TIME AM 06/01/2006 06/01/2007 DIRECT BILL :PM AGENCY BILL NAME (First Named Insured & Other Named Insureds) rcm VK zvv ace * UUu_Uu_UUIUlU i MAILING ADDRESS INCLZIP+4 of First Named Insured) Larimer Insured): City of Fort Collins PHONE ".P.O. BOX 580 PM); - 'Fort Collins, CO 80522 ..... .. . ....... SUBCHAPTER "S": :NOTFOR OR BUREAU ID NUMBER YEAR BUS INDIVIDUAL CORPORATION CORPORATION .... PROFITORG' NAME STARTED PARTNERSHIP JOINTVENT R h IMITED X :Other QRpQRATJDN. .. ..... .. . .. .... . INSPECTION CONTACT PHONE ACCOUNTING RECORDS CONTACT PHONE ............ �: .(Nq,-Nql g*t]: ........................... ... ...... STREET, CITY, COUNTY STA7E VP+4 CITY LIMITS i INTEREST YR BUILT PART OCCUPIED INSIDE OWNER OUTSIDE :TENANT ...... ..... .... ..... INSIDE ... ...... ... . ...... .. ........ .. . .......................... ..... .. .. ..... ..... OWNER OUTSIDE :TENANT INSIDE OWNER OUTSIDE :TENANT .... .. ..... .... .......... . -RESPONSES ...... I_— ...... . N 1. IS THE APPLICANT A SUBSIDIARY OF ANOTHER ENTITY OR DOES ; 7. ANY PAST LOSSES OR CLAIMS RELATING TO SEXUAL ABUSE OR :1 ...... THE APPIICANT.MVEAt4.Y.SURSIDLARIES7 ............ .......... ............ ........... .......... .. ...... ...... WLESTATtON.,ULECATIONS,.DI$CPJMIUATIONDR.NEGUGENT.HLRING? ....... . . ...... ;2. IS A.IPPRIVIAL.W.ETYPROGRAM IN OPERATION?.... ...... B. DURING THE LAST TEN YEARS, HAS ANY APPLICANT BEEN CONVICTED OF ANY DEGREE OF THE CRIME OF ARSON? (in Fit, this on mml be _ANY EYPO SURE. T Q. flAM ..................... .. . ............ sn�ed by any applicant for prop" Insurance. Failure lowoe the existence of an arson cmvviction is a misdemeanor punisby a A., ANY CATA3TRO.P.HEEXPOSURF7 .... ............. ap.risonme ), . ........... ..... 6. ANY POLICY OR COVERAGE DECLINED, CANCELLED OR NON -RENEWED DURING THE-PRIOR3 YEARS? NOTAPPLICABUEINMO ...... ............ ... ....... . 10. ANY BANKRUPTCIES TAX OR CREDIT LIENS AGAINST THE APPLICANT IN THE PAST SNEAFtt? REMARKS ffoxf om BENEFITS MAY AL Y A'CAAPRODUCERS PL ES SIP GNATU R E YZ SIGNATURE ACORD 125 (7/98) el 17 PLEASE COMPLETE REVERSE sinr Q ACORD CORPORATION 1993 a DATE(MMIDOM' ACORD®` ��t��,�» r < <°��`," os/lzjzoo6 .....%�.,.., 12 ... .... PRODUCER PHONE (303)773-9999 APPLICANT FAX (303)773-9776 City of Fort Collins_..,,,. ............. V. PROPOSED EFF. DATE PROPOSED EXP. DATE BILLING PLAN PAYMENT PLAN PREM. ADJ. a:: _...................... _.... _.................. ...... ... _........ _............. ................... .......,..................Y-."' _.-...................... _........,...... Arthur J. Gallagher Risk Management Sergi;;;; AGENCY 6399 S. Fiddlers Green Circle " 06/01/2006 06/01/2007 DIRECT Suite SUlte ZOO {: FOR COMPANY U.S ONLY .......... ......_............................ :......... :............... ..._............................. ..... .......:................. E Greenwood Village, CO 80111 n t .J.x>:, f{.`.x`.`5".. ,fia<,>n,.i •c %>:>a va)i �'S{; ',` E�aA:, uJ•a a tr s. L ;. n� J t#,v, t., ..�:f. ,:2>J':+x .5 .?#YSLPpp 21xs Y. +Yi+ �u: �r '3. #'{: £ ,1 # .:�' '�'#^'{':Vr 1R (J)„p I�{ i�&•�'.'a •,{v k �2,J.;. J: �. .. yyaa$�,--.i.>.�3rFFss f- F ;nafx abL;a$$F{J 5('i23s fi.2:'Y, a�'ii,vit v• £>. tlR,"Gw a t� 2 `"f�Q�}#�.} t»k`T 1�. v£P.t .¢! Jt}R ¢w r 3Ex�sRuf;S 4>>{Ex+wy>w� iFY »:nv �Y�$I.�l`�:4�i., s>'3a;.i�::,�;�e inl.9 WJn nivn.,i../.iv.Ka rvm ��vr 'nv'v'nv'v�tx',�P� LIMIT AT ANY SINGLE LIMIT PER LIMIT ATA TEMPORARY TRANSITf' CAUSES OF LOSS SUB LIMIT DEDUCTIBLE ;;..... _.............................. i....._................................. LOCATION DISASTER LOCATION f LIMIT :EARTHQUAKE 'S FLOOD f SPECIAL :BROAD (BASIC ... J.a:Yn.:>:.': Rv:.F... :: n. .5 n:Y..iJ':; .. ..5 ... .iv ... : .S :•1rn:.:. tiv!>:. i;.. G'�J:n_$;n::.a.::.,.::�S;J:, v,..n„':E n n n : ix.. ... n.m ... .. .. .: E .. .. ..4r.\Y .i :w) ,. C. :...:.f.,L. J v.•.i R,.ni.m. +:n:...+.. ':i.`ti'`:::,.. y� af..6 .i G$ ! >' tr 5 n :xnca �>.> •�,.2L;v)..., Jd>it. St?$ i tr .5.55< ES 2R}S: k + `b`K >'3 SxE�. rS. "'Jk�t��`Li:(tJ.�A i'�' C :>A .i>a; P.'... a. .t s, F. >,»:,:. c..;;. ,.; v""<>. .x ,n n... 3i?�?":'at,`•.fi?!iitu >A..y:,;\vq: ;: P. .J.. ::, :..tu�,i.;..:zvRJ..)a:r� ..:+T.n.:.a.................: is J::J,.?aii o>aEixro.•?>, .,, rv.. ....-..:. ._.. ..... ... t.1n .. -. n„Y��a,�.. J. .,.. �. .....(.... ... ..; ., a,... ... ... .. ,a SPECIFY THE APPLICANTS OPERATING TERRITORY:` ENTER THE GROSS INSTALLATION RECEIPTS. ._.._..GRSSIN.T _..._...................._ (ESTIMATE)..... _.., PAST 12 MONTHS NEXT 12 MONTHS T�J{�V�V :., rr _ _ as a ..<)Sx- ♦ � �> f'ri f � - < 2. > > 5 M 2 : '. f i i J§:+� � J't� xt MEjl `." A ANNUAL M JOBS IN PROGRESS ' COST OR VALUE OF EACH INSTALLATION TYPE 1 DURATION:""" ...... - '------' - -- -- MATERIAL COST('% of TOW NUMBER - . MAXIMUM 'AVERAGE' MAXIMUM MINIMUM AVERAGE RESIDENTIAL ` f : f S % COMMERCIAL i S $ ? S % G'u:n..<,<2>:: ..kv:>:.'":>3;iJ`• s.:5<:o wi(G':%i'%kk%:z:f:2:Y':`."^ %;2G):r i'<:'<"' NAME S ADDRESS NAMES ADDRESS INTEREST .INTEREST CERTIFICATION CERTIFICATION REQUIRED REQUIRED NAME 8 ADDRESS NAME S ADDRE8S ........ .. ................. ........ ... ... .. ....... ........... ........ .... _ _._....____. ._.. _ _.. INTEREST INTEREST CEREQUIRE� N CERTIFICATION REQUIRED .. y..;e.:'<2:S:2Efuff:2:f93•..:�YY;..:. , .::.: +r.::..,..... 'z>)5'e<Sti rv:C.:,1s75:<tm,<af t 3.i, yin SatY aft } 5v`Pu yr >? .',?.>,n;,; "' ..�a��'��•PV L` '•R 1Q' DESCRIBE ALL HOISTING OR OTHER OPERATIONS REQUIRING RIGGING. ;f ESTIMATE TL OF VALUE OF MATERIAL SNIPPED 70 JOB SITE A7 APPLICANTS RISK. t:: DESCRIBE JOB SITE SECURITY REMARKS 5.,{...)5'�.+.:2J..�3NMYfZ Mi},;lii7' t.>.,x.. ii e, t:..:: C' 2..<°72..}xiVPt4:M �NYi'f�RI1dIstWRYA,; ... . ............... .. I �:��X� .11 ... .......... 'n .......... K . .. ......... ..... ..... M, NINE-, . .... ... .. . CAUSES OF LOSS SUB LIMIT DEDUCTIBLE LIMIT ATA TEMPORARY TRANSIT LIMIT ... ... . .............. ........ .. ....... LIMIT ATLOCATION LOCATION EARTHQUAKE SN/A FLOOD ;s N/A N/A 17,733,658 N/A SPECIAL BROAD i BASIC g 5550 R., a*01 R. 13-55F A., .1 - �Mzs ;17 JOB TERM DESCRIBE JOB SITE SECURITY ............... — ...... CONTRACT AMOUNT VALUE OF OWNER COMMENCEMENT COMPLETION SUPPLIED PROPERTY Construction fencing around ................. ........... ...................... ............. . ... ................ ............ , entire facility, I.. locked at 6/6/06 8/1/07 t 21,631,167 S 0 night and lighting. ... ...... .. mludN L�tlon — ACORD 12 DESCRIBE THE WORK TO BE PERFORMED (I5) Construction of a new police station,- 99,878 square feet, steel frame and concrete construction. INSURED'SJOB NUMBER: 30516300 ................. ........................ . ............ NAME & ADDRESS NAME& ADDRESS N� 'M Ell 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 .................... .... ............. .. .... ....... ....... .... ......... 1 .. .... . . ... .... .... INTEREST ............................. INTEREST : .. ..... CERTIFICATION x CERTIFICATION Design/Builder REQUIRED Finance :X REQUIRED ... NAME S ADDRESS NAME& ADDRESS.......... . ..... ....... I ........... INTEREST INT I ER . E . ST I CERTIFICATION REQUIRED CERTIFICATION REQUIRED ANEW '10 -,77 - 773 710 .7m 7,77'. 711M X fix. TOTAL VALUES TO BE SHIPPED TO THIS JOB SITE AT APPLICANTS RISK DESCRIBE ALL HOISTING OR OPERATIONS REQUIRING RIGGING. AMOUNTSHIPPED % FOR APPLICANTS % BY COMMONI VEHICLES CONTRACTCARRIER DISTANCE INVOLVED REMARKS I PA Rl 0.10 `1=01 ;19 ER . W.4 M