HomeMy WebLinkAboutSJW TRUCKING - INSURANCE CERTIFICATE (2)03-08-2010 10:14 AMFAM 9704543553 PAGE2
450 05 XN1800-01 001 Jr3A
AMERICAN FAMILY MUTUAL INSURANCE COMPANY
MADISON, WISCONSIN 53783-0001
COMMON DECLARATIONS
POLICY NUMBER COMPANY CODE CUSTOMER BILLING ACCOUNT
05 XN1800-01 0010-ELEK-CO 015-673-451 19
NAMED SJw TRUCKING INC
INSURED
MAILING 11083 HIG14WAY 14
ADDRESS AULT CO 80610-9573
POLICY PERIOD FROM 02/24/2010 TO 02/24/2011
12;01 A.M. Standard Time at your mailing address shown above.
FORM OF BUSINESS: CORPORA'1'lON
BUSINESS DESCRIPTION: SAND Sc GRAVFT. HAUT.FR
In return for the payment of the premium, and subject to all the terms of this policy, we agree with you to provide the insurance as stated in
this policy.
This policy consists of the (ofiawing coverage parts for which a premium is,indicated, this premium may be subject to adjustment.
PREMIUM
COMMERCIAL GENERAL LIABILITY COVEKAGE PART $542,00
TOTAL PREMIUM $542 . 00
AUTHORIZED �• /� COUNTERSIGNED
REPRESENTATIVE V hev�A �F—( / eicr LICENSED PSSIDENI AGW
AGENT 023-316 PAGE 01
CASEY HEATON BRANCH JAA 02-12
216 1ST ST STE 1 ENTRY DATE 01/04/2010
EATON CO 80615-3477
AF DS 00 04 05 AGENT Stock No. 05975
03-08-2010 10:14 AMFAM 9704543553
450 05 XNAA00-01
AMERICAN FAMILY MUTUAL INSURANCE COMPANY
MADISON, WISCONSIN 537833-0001
COMMERCIAL GENERAL LIABILITY COVERAGE PART
DECLARATIONS
POLICY NUMBER
05 XN3800-01
NAMED SJW TRUCKING INC
INSURED
MAILING 11083 HIGHWAY 14
ADDRESS AULT CO 80610-9573
PAGE3
001 JBA
COMPANY CODE
0010-BLBK-CO
LIMITS OF INSURANCE
GENERAL AGGREGATE LIMIT (OTHER THAN PRODUCTS -COMPLETED OPERATIONS) $4 , 000, 000
PRODUCTS -COMPLETED OPERATIONS AGGREGATE LIMIT $4 , G00, 000
PERSONAL & ADVERTISING INJURY LIMIT $2, 000, 000
EACH OCCURRENCELIMIT $2, 000, 000
DAMAGE TO PREMISES RENTED TO YOU LIMIT - ANY ONE PREMISES $100 , 00 0
MEDICAL EXPENSE LIMIT - ANY ONE PERSON $5, 000
LOCATION OF ALL PREMISES YOU OWN, RENT OR OCCUPY
LOCATION 0001 PREMISES 001
11083 HIGHWAY 14
AULT WELD COUNTY CO 80610
CLASSIFICATION PREMIUM
CODE DESCRIPTION BASIS RATE ADVANCE PREMIUM
ALL PRI ALL PR/
OTHER CO OTHER CO
99793 TRUCKERS
PRODUCTS -COMPLETED OVIRRATIONS ARE
SUBJECT TO THE GENERAL AGGREGATE LIMIT
31,500 15,64.5 $493.00
(004) (B)
B=EACH ONE. 'THOUSAND 004=PAYROT,T,
APPLICABLE ENDORSEMENT CHARGES $49.00
CERTIFIED ACTS OF TERRORISM $11.00
TOTAL ADVANCE PREMIUM $ 54 2 .0 0
Forms and endorsements applying to this coverage pad and made part of this policy at time of issue,
CG 21 71 06 08 IL 00 21 07 02 IL 75 26 12 05 CG 00 01 12 07 IL 02 28 09 07
CG 21 47 12 07 IL 00 17 11 98 IL 75 02 06 99 CG 21 60 09 98 CO 21 96 03 05
CG 21 67 12 04 CG 77 14 04 02 IL 09 85 01 08 CG 20 10 07 04
AGENT 023-316
CASEY HEATON
216 IST ST S'TE 1
EATON
CG AF 01 07 98
CO 80615-3477
PAGE 01
BRANCH �TBA 02-12
ENTRY DATE 01/04/2010
AGENT Stock No. 05981
03-08-2010 10:15 AMFAM 9704543553
450
POLICY NUMBER
0$ XN3800-01
AUTHORIZED
REPRESENTNTATNE p,e4xnt
AGENT 023-316
CASEY HEATON
216 1ST ST STE 1
EATON
CG AF 01 07 96
o5 xN3aoo-oi
AMERICAN FAMILY MUTUAL INSURANCE COMPANY
t MADISON, WISCONSIN 537n0001
COMMERCIAL GENERAL LIABILITY COVERAGE PART
DECLARATIONS
lll� , ��'
CO 80615-3477
AGENT
COUNTERMNE0
LICENSED RESIDENT AGENT
PAGE4
001 JBA
COMPANY CODE
0010-PLEK-CO
PAGE 02
BRANCH JBA 0 2 -12
ENTRY DATE 01/04/2010
Stock No. OS981
03-08-2010 10:15 AMFAM 9704543553
450
PAGES
05 XN3800-01 001 JPA
POLICY NUMBER: 05 XN3800-01
COMMERCIAL GENERAL LIABILITY
CG 2010 07 04
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
ADDITIONAL INSURED — OWNERS, LESSEES OR CONTRACTORS — SCHEDULED PERSON OR
ORGANIZATION
This endorsement modifies insurance provided under the following:
COMMERCIAL GENERAL LIABILITY COVERAGE PART
SCHEDULE
Name Of Additional Insured Person(S) Or Organization(s):
AGGREGATE INDUSTRIES
CITY OF FORT COLLINS
JW TRUCKING
Location(s) Of Covered Operations:
All locations where the Named Insured is performing ongoing operations
for the Named Additional Insured Person(s) or Organizations(s).
Information required to complete this Schedule, if not shown above, will be shown in the Declarations.
A. Section II — Who Is An Insured is amended to include as an injury", "property damage" or "personal and advertising injury"
additional Insured the person(s) or organization(s) shown in caused, in whale or in part, by:
the Schedule, but only with respect to liability for "bodily 1. Your acts or omissions; or
Page 1 of 2
CG 2010 07 04 0 ISO Properties, Inc., 2004 Stock No. 0578t