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Home My WebLink AboutJANSMA BROTHERS EXCAVATING - INSURANCE CERTIFICATEDATE (MM °D YYYY) ACORD CERTIFICATE OF LIABILITY INSURANCE OP ID RC JANSM-3 05 22 08 PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE LEN Insurance Agency HOLDER THIS CERTIFICATE DOES NOT AMEND EXTEND OR 4848 Thompson Pkwy ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW Johnstown CO 80534 Phone 970-635-9400 Fax 970-635-9401 INSURERS AFFORDING COVERAGE NAIC 0 INSURED INSURER A swuncasn .c.c. e.. ,,....,. r:... Jansma Bros Excavating 6 Trucking Corp 1040 S Railroad Ave Loveland CO 80537 A-en;t:T_T1C14--i INSURER B Pinnacol Assurance INSURER C INSURER D 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 IN*K LTR RVIJ IINSR TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE DATE MM/DD POLICY EXPIRATION DATE MMID LIMITS A GENERAL LIABILITY X COMMERCIAL GENERAL LIABILITY CLAIMS MADE ® OCCUR X Blanket Add r l Ins CPP0117096 04/01/08 04/01/09 EACH OCCURRENCE E 1 r 000 r 000 PREMISESEa occurence $100,000 MED EXP (Any one person) $1D 000 PERSONAL 8 ADV INJURY $1 r 000 r 000 X Blanket Waiver GENERAL AGGREGATE E 2 r 000 r 000 GEN L AGGREGATE LIMIT APPLIES PER POLICY 7 JECT LOC PRODUCTS COMP/OP AGG E 2 r 000 r 000 A AUTOMOBILE LIABILITY ANVAUTO ALL OWNED AUTOS SCHEDULED AUTOS HIRED AUTOS NON OWNED AUTOS BAP0117096 04/01/08 04/01/09 CO BINEDt) (EaCOMBINED SINGLE LIMIT E1 DDD DDD r r X BODILY INJURY (Per person) $ R BODILY INJURY (Per amdent) S X PROPERTY DAMAGE (Per amdent) E GARAGE LIABILITY ANY AUTO AUTOONLY EAACCIDENT E OTHER THAN EA ACC AUTO ON AUTO ONLY qGG $ E A EXCESMMBRELLA LIABILITY R I OCCUR 7CLAIMSMADE DEDUCTIBLE RETENTION $ UMB0117096 04/01/08 04/01/09 EACH OCCURRENCE E 1 000,000 AGGREGATE E1,000 000 E $ E B WORKERS COMPENSATION AND EMPLOYERS LIABILITY ANY PROPRIETOR/PARR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? I/yea dssW1,s under SPECIAL PROVISIONS below 2342390 06/01/08 06/01/09 X TORVLINTUS I I ER EL EACH ACCIDENT $10D/ 000 E L DISEASE EA EMPLOYEE E 100 000 EL DISEASE POLICY LIMII — $50D 000 OTHER DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES / EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS Certificate holder is listed as additional insured in respects to the General Liability FORT CO SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATETHEREOF THE ISSUING INSURERWILL ENDEAVOR TO MAIL 30 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT BUT FAILURE TO DO SO SHALL City of Fort Collins IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR P O BOX 580 REPRESENTATIVES Fort Collins CO 80522 AUT AE RESEfyr:TRT. ral.l al r1.\ it Td6FCF.T 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