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A CORD � CERTIFICATE OF LIABILITY INSURANCE
DATE (MMIDD[Y
02/27/2009 YYY) ,
PRODUCER
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
Flood & Peterson Insurance Inc
4821 Wheaton.Drive
ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
P O Box 270370'
Fort Collins, CO 80527
INSURERS AFFORDING COVERAGE
NAIC #
INSURED
Tri-City Construction, Inc.
Dennis Kraus dba
P. O. Box 172
Bellvue, CO 80512
INSURERA: United Fire & Cas. _
INSURER B:
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.
I
LTR
NSR
TYPE OF INSURANCE
POLICY NUMBER
POLICY EFFECTIVE
DATE MM/DDIYY
POLICY EXPIRATION
DATE MM/DD/YY
LIMITS
A
GENERAL LIABILITY
60308707
03/07/09
03/07/10
EACH OCCURRENCE
$1 000 000
X COMMERCIAL GENERAL LIABILITY
DAMAGE TO RENTED
PREMISES Ea c rr n
$100 000
CLAIMS MADE Ex_] OCCUR
MED EXP (Any one person)
$5 000
PERSONAL & ADV INJURY
$1 000 000
GENERAL AGGREGATE
$2 000 000
GEN'L AGGREGATE LIMIT APPLIES PER:
PRODUCTS - COMP/OP AGG
s2,060,000
POLICY PRO LOC
JECT
AUTOMOBILE
LIABILITY
ANY AUTO
COMBINED SINGLE_LIMIT
(Ea accident)
$
BODILY INJURY
(Per person)
$
ALL OWNED AUTOS
SCHEDULED AUTOS
BODILY INJURY
(Per accident)
$
HIRED AUTOS
NON -OWNED AUTOS
PROPERTY DAMAGE
(Per accident)
$
GARAGE LIABILITY
AUTO ONLY - EA ACCIDENT
$
OTHER THAN EA ACC
$
ANY AUTO
$
AUTO ONLY: AGG
EXCESS/UMBRELLA LIABILITY
EACH OCCURRENCE
$
OCCUR CLAIMS MADE
AGGREGATE
$
$
DEDUCTIBLE
$
RETENTION $
WORKERS COMPENSATION AND
WC STATU- OTH-
T Y IMIT R
EMPLOYERS' LIABILITY
ANY PROPRIETOR/PARTNER/EXECUTIVE
E.L. EACH ACCIDENT
$
E.L. DISEASE - EA EMPLOYE
$
OFFICER/MEMBER EXCLUDED?
If yes, describe under
SPECIAL PROVISIONS below
E.L. DISEASE -POLICY LIMIT
$
OTHER
DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES / EXCLUSIONS ADDED BY ENDORSEMENT / SPECIAL PROVISIONS
Contractors License
CERTIFICATE HOLDER CANCELLATION
City of Fort 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 -1 f) 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
REPRESENTATIVES.
AUTHORIZED REPRESENTATIVE
'r P4_A.,Pe"00.j ,�Ng✓I a+ar,Je� , �ealc-,
ACORD 25 (2001/03) 1 of 2 #S437796/M437795 TLA O ACORD CORPORATION 1988
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 2 #S437796/M437795