HomeMy WebLinkAboutJANSMA BROS EXCAVATING - INSURANCE CERTIFICATEACORQ CERTIFICATE OF
LIABILITY INSURANCE OPID RC DATE (MMIDD YY )
JANSM-3 03 18 09
PRODUCER
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
LBN Insurance Agcy-Johnstown
HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
4848 Thompson Pkwy, Ste 200
ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
Johnstown CO 80534
Phone: 970-635-9400 Fax: 970-635-9401
INSURERS AFFORDING COVERAGE
NAIC#
INSURED
INSURER A: mountain states Insurance Grp
INSURER B: P±nnacol Assurance
41190
Jansma Bros. Excavating
---__—_--
& Trucking,Corp.
INSURER C:
1040 S. Railroad Ave.
_ _
INSURER D:
Loveland CO 80537
- ------ ---.
- ----
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.
INS
LTR
IT
NSR
TYPE OF INSURANCE
POLICY NUMBER
POLICY EFFECTIVE
DATE MMIDOM'
EXPIRATION
POLICY
DATE MMIDDM'
LIMITS
GENERAL LIABILITY
EACH OCCURRENCE
$ 1 , 000 , 000
A
X COMMERCIAL GENERAL LIABILITY
CPP0117096
04/01/09
04/01/10
DAMAGE TO
PREMISES Eaolccurence)
$ 100,000
CLAIMS MADE X OCCUR
M E D E X P (Any one person)
S 10,000
PERSONAL & ADV INJURY
$1,000,000
X Blanket Addrl Iris
X Blanket Waiver
GENERAL AGGREGATE
s2,000,000
PRODUCTS - COMP/OP AGG
s2,000,000
GENT AGGREGATE LIMIT APPLIES PER:
POLICY PECROT LOD
J
AUTOMOBILE
LIABILITY
COMBINED SINGLE LIMIT
$1 000,000
X
A
ANY AUTO
BAP0117096
04/01/09
04/01/10
(Ea accident)
ALL OWNED AUTOS
BODILY INJURY
S
SCHEDULED AUTOS
(Per person)
X
HIRED AUTOS
BODILY INJURY
5
X
NON -OWNED AUTOS
(Per accident)
PROPERTY DAMAGE
$
(Per accident)
GARAGE LIABILITY
AUTO ONLY - EA ACCIDENT
$
OTHER THAN EA ACC
$
ANY AUTO
5
AUTO ONLY: AGO
EXCESS/UMBRELLA LIABILITY
EACH OCCURRENCE
S1,000,000
A
X OCCUR L�CLAIMSMADE
UMB0117096
04/01/09
04/01/10
AGGREGATE
51,DOO,DDD
5
DEDUCTIBLE
RETENTION $
5
WORKERS COMPENSATION AND
X TORV LIMITS ER
B
EMPLOYERS' LIABILITY
2342390
06/01/08
06/01/09
"-"'
EL EACH ACCIDENT
$ 100,000
ANY PROPRIETOR/
/MEMBER EXCLUDED?
EXCLUDED?
Oyes,
E.L. DISEASE - EA EMPLOYEE$
1 D D , D D D
de ISJer
If SPECIAL
SPECIALPROVISIONSbelow
- - AMITI
E.L. DISEASE-POUCY LIMIT
s------
$5D0 000
OTHER
DESCRIPTION OF OPERATIONS I LOCATIONS [VEHICLES / EXCLUSIONS ADDED BY ENDORSEMENT / SPECIAL PROVISIONS
Certificate holder is listed as additional insured in respects to the
General Liability.
CERTIFICATE HOLDER CANCELLATION
FORT CO I SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION
DATE THEREOF, THE ISSUING INSURER WILL 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 I IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR
P.Q. BOX 580 REPRESENTATIVES.
Fort Collins CO 80522 1 AUT 1*fflRESE)7ATIV€, a u ii A,A,
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.
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