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Home My WebLink AboutDON KEHN CONSTRUCTION INC - INSURANCE CERTIFICATEClient#: 52210 8DONKEHN ACORD., CERTIFICATE OF LIABILITY INSURANCE DATE 11/01/08Omvv) PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION HRH of Colorado ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE 720 South Colorado Boulevard HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Suite 60ON Denver, CO 80246 INSURERS AFFORDING COVERAGE NAIC # INSURED Don Kehn Construction, Inc. 6550 SCR5 Fort Collins, CO 80528 INSURER A'. Zurich American Insurance 16535 INSURERS: Everest National Insurance Co. 10120 INSURERC: PinnacolAssurance 41190 INSURER D: ,SURER 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 NSR TYPE OF INSURANCE POLICY NUMBER POLICYEFFECTIVE DATE MMIDDm POLICYEXPIRATION DATE MMIDDIYY LIMITS A GENERAL LIABILITY CP05942579 11/01/08 11/01/09 EACH OCCURRENCE $1000000 COMMERCIAL GENERAL LIA81LITY CLAIMS MADE a OCCUR DAMAGE TO RENTEDPREMISES Ea ocOnencet $300OOO MED EXP (Any one person) $5 000 PERSONAL & ADV INJURY $1 00Q 000 AI# U-GL-1175-B CW (3/2007) GENERAL AGGREGATE s2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP/OP AGO s2,000,000 POLICY X PRO CT OC A AUTOMOBILE LIABILITY ANY AUTO CP05942579 11/01/08 11/01/09 COMBINED SINGLE LIMIT (Ea accident) $1,000,000 X BODILY INJURY (Per person) $ ALL OWNED AUTOS SCHEDULED AUTOS X BODILY INJURY (Par accitlenl) $ HIREDAUTOS NON -OWNED AUTOS X X PROPERTY DAMAGE (Per accident) $ Ltd Pollution GARAGE LIABILITY AUTO ONLY - EA ACCIDENT $ OTHER THAN EA ACC $ ANY AUTO $ AUTO ONLY: AGO B EXCESS/UMBRELLA LIABILITY 71CH000023081 11/01/08 11/01/09 EACH OCCURRENCE $2000000 X OCCUR CLAIMS MADE AGGREGATE s2,000,000 $ $ DEDUCTIBLE $ RETENTION $ C WORKERS COMPENSATION AND 2093950 10/01/08 10/01/09 X WC STATU- DTH- Q8Y11MB:5. �B EMPLOYERS' LIABILITY ANY E.L. EACH ACCIDENT $500 000 E.L. DISEASE - EA EMPLOYEE $500,000 OFFICER/MEMBER EXCLUDED? OFFICERIMEMBER EXCLUDED? If yes, describe under SPECIAL PROVISIONS below E.L. DISEASE -POLICY LIMIT $500,000 OTHER DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS Project Description: 6045 Asphalt Supply (See Attached Descriptions) City of Fort Collins Administrative Services Purchasing Division PO Box 580 Fort Collins, CO 80522-0580 ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION IEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL Rn* DAYSWRITTEN TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR HV VRU LD (LUU LUO) 9 Ot 3 Ili 146b SMJ 1 T d, rvvmd, i vrcrvnr I Ivn rnoo IMPORTANT If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). DISCLAIMER The Certificate of Insurance on the reverse side of this form does not constitute a contract between the issuing insurer(s), authorized representative or producer, and the certificate holder, nor does it affirmatively or negatively amend, extend or alter the coverage afforded by the policies listed thereon. ACORD 25-S (2001/08) 2 of 3 #M611465 Cliont$� 5991n SDONKEHN ACORDe, CERTIFICATE OF LIABILITY INSURANCE DATE 11/01/08Dnrvv) PRODUCER HRH of Colorado 720 South Colorado Boulevard 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. Suite 60ON Denver, CO 80246 INSURERS AFFORDING COVERAGE NAIC If INSURED INSURERA: Zurich American Insurance 16535 _ Don Kehn Construction, Inc. 6550 SCR5 Fort Collins, CO 80528 I INSURER B: Everest National Insurance Co. 10120 INSURERC Pinnacol Assurance 41190 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, ILTRNSft R DD' OF INSURANCE POLICY NUMBER POLICYEFFECTIVTYPE DATE (MMIDOnYE POLICY MMIDDfYY EXPIRATION LIMITS A GENERAL LIABILITY COMMERCIAL GENERAL LIABILITY CLAIMS MADE 51OCCUR [] AI#U-GL-1175-BCW CP05942579 11/01/08 11/01/09 EACH OCCURRENCE $1000000 DAMAGE S.TO RENTED 5300000 MED EXP (Any one person) $5 000 PERSONAL BADVINJURY $1000000 (3/2007) GENERAL AGGREGATE 52 000 000 GEN'L AGGREGATE LIMIT APPLIES PER: POLICY PRO- JECT OC X PRODUCTS - COMP/OP AGG s2,000,000 A AUTOMOBILE LIABILITY ANY AUTO ALL OWNED AUTOS SCHEDULED AUTOS HIRED AUTOS NON -OWNED AUTOS Ltd Pollution CP05942579 11/01/08 11/01/09 COMBINED SINGLE LIMIT (Ea accident) $1,000,000 X BODILY INJURY (Per person) $ X BODILY INJURY (Per accident) $ X X PROPERTY DAMAGE (Per accident) $ GARAGE LIABILITY ANY AUTO AUTO ONLY - EA ACCIDENT $ OTHERTHAN EA ACC AUTOONLY: AGG $ $ B EXCESSIUMBRELLA LIABILITY OCCUR F_ICLAIMS MADE DEDUCTIBLE RETENTION $ 71CH000023081 11/01/08 11/01/09 EACH OCCURRENCE $2000000 X AGGREGATE $2,000 000 5 $ $ C WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANY PROPRIETORIPARI'NERIEXECUTIVE OFFICER/MEMBER EXCLUDED? If yes, describe under SPECIAL PROVISIONS below 2093950 10/01/08 10/01/09 X WC'LIMIJ 2 E.L. EACH ACCIDENT $500,000 E.L. DISEASE - EA EMPLOYEE s500,000 E.L. DISEASE -POLICY LIMIT $500,000 OTHER DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS Project Description: Mining Reclamation Agreement regarding Arapahoe Bend Natural Area. (See Attached Descriptions) City of Ft. Collins PO Box 580 Fort Collins, CO 80522.0580 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL '10' DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR ACORD 25 (2001/08) 1 of 3 #M611465 BMSTY is vwrcv wrcrvrcH l IVIN Iwoo 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. AUUMU zo-o tzuuvuol 2 W 3 #M611465 Client#: 52210 8DONKEHN ACORD. CERTIFICATE OF LIABILITY INSURANCE 11/01/OSD'YYwI PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION HRH of Colorado ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE 720 South Colorado Boulevard HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Suite 60ON Denver, CO 80246 INSURERS AFFORDING COVERAGE NAIC # INSURED Don Kehn Construction, Inc. 6550 SCR5 Fort Collins, CO 80528 INSURER A: Zurich American Insurance 16535 wNational suRERB; Everest lnusurance Co. 10120 INSURERC: Pinnacol Assurance 41190 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 ADD1POLICY NSR TYPE OF INSURANCE POLICY NUMBER EFFECTIVE DATE MMIDDIYY POLICY EXPIRATION DATE MMIDDIYY LIMITS A GENERAL LIABILITY CP05942579 11/01108 11/01/09 EACH OCCURRENCE_ $1000000 COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTEDPREMISES fEa occurrence) $300OOO CLAIMS MADE FxI OCCUR MED EXP (Any one person) $5 000 PERSONAL & ADV INJURY $1000000 AI#U-GL-1175-BCW (3/2007) GENERAL AGGREGATE $2 00O 000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP/OP AGG $2000000 POLICY X PRO- LOC A AUTOMOBILE LIABILITY ANY AUTO CP05942579 11101/08 11/01/09 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) $ Ltd Pollution GARAGE LIABILITY AUTO ONLY - EA ACCIDENT $ OTHERTHAN EA ACC $ ANY AUTO $ AUTO ONLY: AGG B EXCESSIUMBRELLA LIABILITY 71CH000023081 11/01/08 11/01/09 EACH OCCURRENCE $2000.000_ X OCCUR F—ICLAIMS MADE AGGREGATE $210001_000 $ DEDUCTIBLE $ RETENTION $ C WORKERS COMPENSATION AND 2093950 10/01/08 10/01/09 X WCSTATU- OTH- EMPLOYERS' LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE E.L. EACH ACCIDENT" $SOO,000 E.L. DISEASE - EA EMPLOYEE $SOO,O02 OFFICERIMEMBER EXCLUDED? If yes, describe under SPECIAL PROVISIONS below E.L. DISEASE - POLICY LIMIT $500,000 OTHER DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS Project Description: Furnishing Asphalt (See Attached Descriptions) City of Ft. Collins ATTN: Director of Purchasing & Risk Management P. 0. Box 580 Ft. Collins, CO 80522.0580 LD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 3W 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 AUUKU cD (tuU'DU0) 1 Ot 3 #M511465 SM5 I Y w AUUMIJ I July I U00 11 UOTETEM 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 #M611465 DESCRIPTIONS (Continued from Page 1) The following are Additional Insureds as respects General Liability only if required by written contract and coverage applies only as respects work performed by the Insured for the Additional Insureds. All coverage terms, conditions and exclusions of the policy apply. Additional Insureds: City of Fort Collins The Additional Insured endorsement which is referenced above under "Type of Insurance -General Liability" is attached. This Certificate of Insurance represents coverage currently in effect and may or may not be in compliance with any written contract. 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 Commissioner of Insurance AMs 25.3 (2001/08) 3 of 3 #M611465 Additional Insured — Automatic — Owners, Lessees Or Contractors 0 ZURICH Policy No. Exp. Date of Pal. Efr. Date of End. Agency No. Add]. Prem. Return Prem. THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. Named Insured: Address (including ZIP Code): This endorsement modifies insurance provided under the: Commercial General Liability Coverage Part A. Section II — Who Is An Insured is amended to include as an insured any person or organization who you are re- quired to add as an additional insured on this policy under a written contract or written agreement. B. The insurance provided to the additional insured person or organization applies only to "bodily injury", "property damage" or "personal and advertising injury" covered under SECTION I - Coverage A - Bodily Injury And Prop- erty Damage Liability and Section I - Coverage B - Personal And Advertising Injury Liability, but only with respect to liability for "bodily injury", "property damage" or "personal and advertising injury" caused, in whole or in part, by: 1. Your acts or omissions; or Z. The acts or omissions of those acting on your behalf; and resulting directly from: a. Your ongoing operations performed for the additional insured, which is the subject of the written contract or written agreement; or b. "Your work" completed as included in the "products -completed operations hazard", performed for the addi- tional insured, which is the subject of the written contract or written agreement. C. However, regardless of the provisions of paragraphs A. and B. above: 1. We will not extend any insurance coverage to any additional insured person or organization: a. That is not provided to you in this policy; or b. That is any broader coverage than you are required to provide to the additional insured person or organiza- tion in the written contract or written agreement; and 2. We will not provide Limits of Insurance to any additional insured person or organization that exceed the lower of: a. The Limits of Insurance provided to you in this policy; or b. The Limits of Insurance you are required to provide in the written contract or written agreement. Includes copyrighted material of Insurance Services Office, Inc., with its permission, U-GL-1 I75-B CW (3/2007) Page I oft D. The insurance provided to the additional insured person or organization does not apply to: "Bodily injury", "property damage" or "personal and advertising injury" arising out of the rendering or failure to ren- der any professional architectural, engineering or surveying services including: 1. The preparing, approving or failing to prepare or approve maps, shop drawings, opinions, reports, surveys, field orders, change orders or drawings and specifications; and 2. Supervisory, inspection, architectural or engineering activities. E. The additional insured must see to it that: 1. We are notified as soon as practicable of an 'occurrence" or offense that may result in a claim; 2. We receive written notice of a claim or "suit" as soon as practicable; and 3. A request for defense and indemnity of the claim or "suit" will promptly be brought against any policy issued by another insurer under which the additional insured may be an insured in any capacity. This provision does not apply to insurance on which the additional insured is a Named Insured, if the written contract or written agree- ment requires that this coverage be primary and non-contributory. F. For the coverage provided by this endorsement: 1. The following paragraph is added to Paragraph 4.a, of the Other Insurance Condition of Section IV — Com- mercial General Liability Conditions: This insurance is primary insurance as respects our coverage to the additional insured person or organization, where the written contract or written agreement requires that this insurance be primary and non-contributory. In that event, we will not seek contribution from any other insurance policy available to the additional insured on which the additional insured person or organization is a Named Insured. 2. The following paragraph is added to Paragraph 4.b. of the Other Insurance Condition of Section IV — Com- mercial General Liability Conditions: This insurance is excess over: Any of the other insurance, whether primary, excess, contingent or on any other basis, available to an additional insured, in which the additional insured on our policy is also covered as an additional insured by attachment of an endorsement to another policy providing coverage for the same "occurrence", claim or "suit". This provision does not apply to any policy in which the additional insured is a Named Insured on such other policy and where our policy is required by written contract or written agreement to provide coverage to the additional insured on a primary and non-contributory basis. G. This endorsement does not apply to an additional insured which has beer added to this policy by an endorsement showing the additional insured in a Schedule of additional insureds, and which endorsement applies specifically to that identified additional insured. Any provisions in this Coverage Pail not changed by the terms and conditions of this endorsement continue to apply as written. 111cllides copyrighted material of insurance Services Office, Inc., with its permission. U-GL-1175 B CW (3/2007) Page 2 of 2