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Home My WebLink About172218 PINNACOL ASSURANCE - PURCHASE ORDER - 8851282Date 02/29/08 7� City of Fort Collins Citv of FCoils Page Number 1 Vanden 172218 PINNACOL ASSURANCE DEPT 900 DENVER CO 60281.0600 Purchase Order Number 8851282 Ship To PUBLIC LIBRARY 201 P TERSON S' FORT COLLINS C Delivery Date 02/29/08 B er CAREY, DAVID Purchase Order number must appear on invoices packing lists, labels ills of lading and all correspondence Note Line Qty/Units Description Extended Price 1 1 Lot 9 228 00 POLICY # 4118811 Coverage Period 04/01/08 to 04/01/09 PerINV# 14330742 Workers Compension Coverage Total $9,228 00 This order is r1olhalid over $2000 unless signed by James B O Neill II CPPO FNIGP City of Fort Collins Accounting Department City of Fort Collins Purchasing PO Box 580 Fort Collins CO 80522 0580 PO Box 580 Phone 970 221 6775 Fax 970 221 6707 Email purchasing@fcgov com Fort Collins CO 80522 0580 Pmnacol Assurance appreciates your business, P/NN A coL Thank you for being a loyal customer since 2007 ASSURANCE Workers' Compensation Invoice Contact Information Agent FLOOD S PETERSON IN 970 266 8710 Pmnacol Assurance (Denver) 303 361 4000 (Toll Free) 800 873 7242 Business Hours Mon Fn 8 AM 5 PM Online www prnnacol corn FORT COLLINS REGIONAL LIBRARY DISTRICT 201 PETERSON STREET FORT COLLINS CO 80524 Page 1 of 3 W 1100 4118811 12131/2007 14330742 02/25/2008 $0 00 $0 00 $0 00 $1 025 00 $1 02500 03117/2008 Policy Information - - --- - — - Your renewal policy premium for 04/01/2o08 to 04/01/2009 Is estimated at $9 228 00 Your remaining balance is $9 228 00 Premiums are subject to change Your policy premium for 12/31/2007 to 04/01/2008 Is estimated at $2 527 00 Your remaining balance is $0 00 Premiums are subject to change Account Information Policy Number Policy Period Invoice Number Invoice Date Billing Information Previous Balance Amount Applied Prior Balance Installment Charges $1 025 00 Othel Balance $0 00 Current Total Total Due Due Date Important Information PLEASE REMEMBER TO REPORT ALL WORKPLACE INJURIES WITHIN 24 48 HOUR Please Account Information Make check payable to Pmnacol Assurance Include your Policy Number on the check Policy Number 4118811 /� indicate any change of address on the reverse side INN/,1 COL Wile any que (ions or comment on a separate enclosure Policy Period 12/31/2007 ASSURANCE Invoice Number 14330742 _ Invoice Date 02/25/2008 Total Due $1 025 00 Due Date 03M7/2008 Name FORT COLLINS REGIONAL L Pinnacol Assurance Check Number Dept 500 Amount Enclosed Denver CO 80281-0500 411881100001 143307429 200802254 000000 0000010250006 ZAUCCIF012 Pinnacol Assurance Workers' Compensation Invoice Coverage Information for Policy 4118811 Location 1 FORT COLLINS REGIONAL LIBRARY DISTRICT 201 PETERSON STREET FORT COLLINS CO 80524 Period 0401 2008 04 01 2009 Class RT QtaLrjat= 881040 EM LIBRARIES MUSED autiK 881105 BD NON SALARIED BO 135 00 700 Total Payroll $3 512 672 Minimum Premium $173 Premium Information Ratable Manual Premium Increased Limits Schedule Rating Designated Provider Discount Annual Policy Fee Foreign Terrorism Dtec Catastrophic Loss Charge Net Estimated Annual Premium Period 0401/2008 04,01,2009 04,0112008 04012009 04/012008 04/01/2009 04012008 04/011'2009 04/01/2008 04'0112009 04/01/2008 04,012009 04/012008 04/01/2009 04/01'2008 04/01 2009 ESTIMATED PREMIUM Payroll Rele Prem-Chi $3 403 472 228000 $7 760 $109 200 047500 $52 Total Premium $7 812 Adiuct[u= Amount 1 017 $7 812 1 000 $133 975 $0 $199 $165 $966 $351 $9 228