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Home My WebLink About267431 NORTHSTAR CONCRETE - INSURANCE CERTIFICATE (3)rlianf*- AR343 NORSTI ACOR M CERTIFICATE OF LIABILITY INSURANCE DATE (MMID 09/06/ 6DIYYYY) PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Flood & Peterson Ins. Inc. P. O. Box 578 ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. 4687 W. 18th Street Greeley, CO 80632 INSURERS AFFORDING COVERAGE NAIC # INSURED Northstar Concrete, Inc. and Manhole Specialists, Inc. P.O. Box Y Berthoud, CO 80513-0739 INSURERA: St. Paul Travelers Insurance Company INSURER B: Pinnacol Assurance INSURER C: 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. LTR NSR TYPE OFINSURANCE POLICY NUMBER POLICY EFFECTIVE DATEMWDDIYYDAT POLICY EXPIRATION E MIDONY) LIMITS A GENERAL LIABILITY DTC04984C834 04/26/06 04/26/07 EACH OCCURRENCE $1 000 000 X COMMERCIAL GENERAL LIABILITY DAMAGE O ENTED $300O0O CLAIMS MADE D OCCUR MED EXP (Any one person) $5 000 PERSONAL & ADV INJURY $1 00O 000 X PD Ded:2,500 GENERAL AGGREGATE $2 00O 000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP/OP AGG $2 OOO OOO 1-1 POLICY PRO- JECT LOC A AUTOMOBILE LIABILITY ANY AUTO DT8104984C834 04/26/06 04/26/07 COMBINED SINGLE LIMIT (Ea accident) $1,000,000 X BODILY INJURY (Per person) $ ALL OWNED AUTOS SCHEDULED AUTOS X BODILY INJURY (Per accident) $ HIRED AUTOS NON -OWNED AUTOS X X PROPERTY DAMAGE (Per accident) $ Drive Other Car GARAGE LIABILITY AUTO ONLY - EA ACCIDENT $ OTHER THAN EA ACC $ ANY AUTO $ AUTO ONLY: AGG A EXCESSIUMBRELLA LIABILITY DTSMCUP4984C834 04/26/06 04/26/07 EACH OCCURRENCE $1 000 000 X1 OCCUR CLAIMS MADE AGGREGATE $1 000 000 $ $ DEDUCTIBLE $ X RETENTION $ 10000 B WORKERS COMPENSATION AND 4108060 09/02/06 09/01/07 X WC STATU- OTH- TORY LIMITS FIR EMPLOYERS' LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE E.L. EACH ACCIDENT $500 000 E.L. DISEASE - EA EMPLOYEE s500,000 OFFICER/MEMBER EXCLUDED? If yes, describe under SPECIAL PROVISIONS below E.L. DISEASE - POLICY LIMIT s500,000 A OTHER Inland QT6609466B366 04/26/06 04/26/07 Marine DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS The following cancellation conditions always apply: -10 days for non-payment of premium - If policy shown, 10 days for Workers' Compensation for fraud; material misrepresentation; non-payment of premium; other reasons approved by the (See Attached Descriptions) City of Fort Collins 215 N. Mason, 2nd Floor Fort Collins, CO 80522 LD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 3_ DAYS WRITTEN :E TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL iE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR AUTHORIZED REPRESENT TIVE Flooat or �t.tessa.�1 Z-Ar✓f A-ajcA , Ti j4c. AL,UKU Z* (ZUUT/US) I of 3 #S357258/M357253 KFP 0 ACORD CORPORATION 1988 DESCRIPTIONS (Continued from Page 1) 1 Commissioner of Insurance AM5 za.s vzuuvuts) 3 of 3 FF5357ZS5)M357253 IMPORTANT If the certificate holder is an ADDITIONAL INSURED, the policy(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. ACORD 25-s (2001/08) 2 of 3 #S357258/M357253