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HomeMy WebLinkAboutJANSMA BROS EXCAVATING AND TRUCKING CORP - INSURANCE CERTIFICATEOP ID KH DATE (MM/DD/YYYY) ACORD CERTIFICATE OF LIABILITY INSURANCE JANSM-3 I 05 08 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 INSURERB: Pinnacol Assurance 41190 Jansma Bros. Excavating INSURER c: & Trucking Corp . 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. LTR INSR TYPE OF INSURANCE POLICY NUMBER DATE (MM DD/YY)EFFECTIVE PDA EY MM/DD/YY N LIMITS A GENERAL LIABILITY X COMMERCIAL GENERAL LIABILITY CLAIMS MADE Fil OCCUR X Blanket Add'l Iris CPP0117096 04/01/09 04/01/10 EACH OCCURRENCE $ 1,000,000 PREMISES (EaoccN I Eurenc.) $ 100,000 MED EXP (Any one person) $ 10,000 PERSONAL & ADV INJURY $1,000,000 X Blanket Waiver GENERAL AGGREGATE s2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: POLICY PRO LOC JECT PRODUCTS - COMP/OP AGG s2,000,000 A AUTOMOBILE LIABILITY ANY AUTO ALL OWNED AUTOS SCHEDULED AUTOS HIRED AUTOS NON -OWNED AUTOS RAP0117096 04/01/09 04/01/10 COMBINED SINGLE LIMIT (Ea accident) $ 1 , 000 , 000 X BODILY INJURY (Per person) $ X BODILY INJURY (Per accident) $ X PROPERTY DAMAGE (Per accident) - $ GARAGE LIABILITY ANY AUTO AUTO ONLY - EA ACCIDENT $ OTHER THAN EA ACC AUTO ONLY: AGG $ $ A EXCESS/UMBRELLA LIABILITY - - X I OCCUR CLAIMSMADE DEDUCTIBLE RETENTION $ - - .. UMB0117096 '04/01/09 04/01/10 EACH OCCURRENCE $ 1,000,000 AGGREGATE $ 1,000,000 $ $ B WORKERS COMPENSATION AND EMPLOYERS'LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE _OFF.ICER/MEMBER.EXCLUDED? If yes, describe under SPECIAL PROVISIONS below 2342390 _- - 06/01/09 06/01/10 X TORY LIMITS ER E.L. EACH ACCIDENT $100,000 E.L. DISEASE - EA EMPLOYEE $ 100 , 000 E.L. DISEASE - POLICY LIMIT I $ 500 , 000 OTHER DESCRIPTION OF OPERATIONS / 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 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 IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR P.O. BOX 580 REPRESENTATIVES. Fort Collins CO 80522 AUT I*A1EyRESEffATI j, ACORD 25 (2001/08) © 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. AGURU 25 (20MIUB)