HomeMy WebLinkAboutJAN PETERSON - INSURANCE CERTIFICATE (2)07/13/2006 10:22 9704842885 BECKETT&ASS. PAGE 01/02
AiCO,RP- CERTIFICATE OF LIABILITY
INSURANCE
DATE
06/1M/6 15 2006 2006
PRODUCER (970) 484-2805
John C. Beckett &Associates, Inc.
220 Smith Street
Ft. Collins CO 80524—
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
INSURERS AFFORDING COVERAGE
NAIC IS
INSURED
Peterson, Jan
39234 Scenic View Court
Ault CO 80610-
INSURER A: PENN- STAR INSURANCE CO
INSURERB:
INSURER0;
INSURER D;
INSURER E:
COVERAGES
THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED, NOTWITHSTANDING ANY
REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,
THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES,
AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
INSR
LTR
DD'L
NSRO
TYPE OF INSURANCE
POLICY NUMBER
POLICY
DATE (EMXMPION
UMITS
A
GENERAL LIABILITY
S COMMERCIAL GENERA). LIABILITY
CLAIMS MADE ERIOCCUR
PAC6586954
/ /
06/07/2006
/ /
/ /
06/07/2007
/ /
EACH OCCURRENCE
$ 500,000
DAMAGE TO RENTED
PREMISES Ea occurrence
$ 100,000
MED EXp Lft one eon
S 5,000
PERSONAL 8 ADV INJURY
$ 500,000
GENERAL AGGREGATE
II 1,060,000
GEN'LAGGREGATE LIMIT APPLIES PER:
X. POLICY JPERO- LOC
PRODUCTS - COMPIOPAGO
S
AUTOMOBILE
LIABILITY
ANY AUTO
ALI.OWNHDAUTOS
SCHEDULED AUTOS
HIRED AUTOS
NON-OWNEDAUTOS
NO COVERAGE
/ /
/ /
/ /
/ /
/ /
/ /
COMBINED SINGLE LIMIT
(Ea aoaldimt)
S
BODILY INJURY
(Per peree°)
$
BODILY INJURY
(Per aooident)
$
PROPERTY DAMAGE
(Per accident)
S
GARAGE LIABILITY
ANY AUTO
NO COVERAGE
/ /
/ /
AUTO ONLY. EA ACCIDENT
$
OTHER THAN EA ACC
AUTO ONLY; AGG
S
S
ExcMSIUMBRELLALIABLITY
OCCUR CLAIMS MADE
DEDUCTIBLE
RETENTION S
NO COVMNGE
/
eAPH QCCURRRNCE
S
AGGREGATE
S
S
$
WORKERS COMPENSATION AND
EMPLOYERS' LIABILITY
ANY PROPRIETORMARTNEWEXECUTiVE
OFFICERIMEMBER FXCWDE07
If yea, describe under
SPECIAL PROVISIONS below
NO CQVZRA09
/
/ /
/ /
/ /
U H
TORY LIMIT OErH.
F
E.L. EACH ACCIDENT
S
E.L. DISEASE • EA EMPLOYEE
S
E,L, DISEASE - POLICY LIMIT
$
OTHER
NO COVERAGE
DESCRIPTION OF OPERATIONSIIACATIONSNEHICLESfRXCLUSIONS ADDED BY ENDORSEMENTISPECIAL PROVISIONS
(970) 221-6760 (970) 221-6707 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE
ATTN: .TAME$ 8 OINEIL EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL
010 GAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE r EFT, BUT
City Of Fort Collins FAILURE TO 00 SO SHALL IMPOSE. NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE
PO Box 580 INSURE ITS AGRNTS OR REPRESENTATIVES.
281 North Co llogo Avonue AUTHORRED REPRESENTATIVE _
Fort Collins CO 80522- -Z. /!
`CORD 25 (2009/08) W ACORD CORPORATION 1988
6•M INS025 (0108)z ELECTRONIC LASER FORMS, INC, • (000)327.OW Pale 1 of 2
07/13/2006 10:22 9704842885 BECKETT&ASS. PAGE 02/02
IT1.1243ACAZk!
If the certificate holder is an ADDITIONAL INSURED, the pollcy(ies) must be endorsed, A statement on this
certificate does not confer rights to the certificate holder in lieu of such endorsement(s).
If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an
endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such
endorsement(s).
DISCLAIMER
The Certificate of Insurance on the reverse side of this form does not constitute a contract between the issuing
insurer(s), authorized representative or producer, and the certificate holder, nor does it affirmatively or negatively
amend, extend or alter the coverage afforded by the policies listed thereon.
ft, INS025 (Otoel.os Pays 2 or 2