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HomeMy WebLinkAbout389648 A-1 CHIPSEAL COMPANY - INSURANCE CERTIFICATE (5)ACORDTM CERTIFICATEOF LIABILITY INSURANCE 5DATE (MM/DD /28/2010"n") PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Willis of Colorado, Inc. 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 INSURER A: Travelers Indemnity Company 25658 DB A Rockyy Mountain Pavement, LLC Chips Company INSURER B: Travelers Property Casualty Company 36161 INSURERC: Pinnacol Assurance 41190 2001 West 64th Lane INSURER D: Denver, CO 80221 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 S LTR NSR TYPE OF INSURANCE ' POLICY NUMBER POLICY EFFECTIVE DATE MM/DD/YY POLICY EXPIRATION DATE MMIDD/YY LIMITS A GENERAL LIABILITY DTC00190P673 10/01/09 10/01/10 EACH OCCURRENCE $1 000OQO X COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTEDPREMISES (Ea occurrence) $300OOO CLAIMS MADE 5_1 OCCUR MED EXP (Any one person) $10 000 PERSONAL & ADV INJURY $1 000 000 X CGD2460805 GENERAL AGGREGATE s2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP/OP AGG s2,000,000 RO- POLICY X PRO LOC B AUTOMOBILE LIABILITY ANY AUTO DT810019OP673 10/01/09 10/01/10 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 PROPERTY DAMAGE (Per accident) $ GARAGE LIABILITY AUTO ONLY - EA ACCIDENT $ OTHER THAN EA ACC $ ANY AUTO $ - AUTO ONLY: AGG B EXCESS/UMBRELLA LIABILITY DTSMCUP0190P673 10/01/09 10/01/10 EACH OCCURRENCE $10000000 _X1 OCCUR CLAIMS MADE AGGREGATE $1 O 00O 000 $ DEDUCTIBLE $ X RETENTION $ 10000 C WORKERS COMPENSATION AND 4055760 10/01/09 10/01/10 TH- X OR LIMITTAT OFR EMPLOYERS' LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE E.L. EACH ACCIDENT $500,000 E.L. DISEASE - EA EMPLOYEE $500,000 OFFICER/MEMBER EXCLUDED? If yes, describe under SPECIAL PROVISIONS below - E.L. DISEASE - POLICY LIMIT s500,000 OTHER DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES / EXCLUSIONS ADDED BY ENDORSEMENT / SPECIAL PROVISIONS Project Description: 2010 Asphalt Slurry Seal Project Number: 6054 The following are Additional Insureds as respects General Liability (See Attached Descriptions) V CRIIr Il..A1C r'IVLUCR City of Fort Collins P O Box 580 Fort Collins, CO 80522 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL *sn 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 AUTHORIZED REPRESENTATIVE A�.VKU ZO (LUUI/IAS) 1 of 3 #S678663/M648763 8WCRO O ACORD CORPORATION 1988 only if required by written contract and coverage applies only as respects ongoing operations performed by the Insured for the Additional Insureds. Additional Insureds: City of Fort Collins All coverage terms, conditions and exclusions of the policy apply. 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 #5678663/M648763 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. J r ACORD 25-S (2001/08) 2 of 3 #S678663/M648763 COMMERCIAL GENERAL LIABILITY THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY BLANKET ADDITIONAL INSURED . (CONTRACTORS) This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART 1. WHO IS AN INSURED — (Section II) is amended to include any person or organization that you agree in a "written contract requiring insurance" to include as an additional insured on this Cover- age Part, but: a) Only with respect to liability for "bodily injury", "property damage" or "personal injury"; and b) If, and only to the extent that, the injury or damage is caused by acts or omissions of you or your subcontractor in the performance of "your work" to which the "written contract requiring insurance" applies. The person or organization does not qualify as an additional insured with respect to the independent acts or omissions of such person or organization. 2. The insurance provided to the additional insured by this endorsement is limited as follows: a) In the event that the Limits of Insurance of this Coverage Part shown in the Declarations exceed the limits of liability required by the "written contract requiring insurance", the in- surance provided to the additional insured shall be limited to the limits of liability re- quired by that "written contract requiring in- surance". This endorsement shall not in- crease the limits of insurance described in Section III — Limits Of Insurance. b) The insurance provided to the additional in- sured does not apply to "bodily injury", "prop- erty damage" or "personal injury" arising out of the rendering of, or failure to render, any professional architectural, engineering or sur- veying services, including: The preparing, approving, or failing to prepare or approve, maps, shop draw- ings, opinions, reports, surveys, field or- ders or change orders, or the preparing, approving, or failing to prepare or ap- prove, drawings and specifications; and ii. Supervisory, inspection, architectural or engineering activities. c) The insurance provided to the additional in- sured does not apply to "bodily injury" or "property damage" caused by "your work" and included in the "products -completed op-. erations hazard" unless the "written contract requiring insurance" specifically requires you to provide such coverage for that additional insured, and then the insurance provided to the additional insured applies only to such "bodily injury." or "property damage" that oc- curs before the end of the period of time for which the "written contract requiring insur- ance" requires you to provide such coverage or the end of the policy period, whichever is earlier. 3. The insurance provided to the additional insured by this endorsement is excess over any valid and collectible 'other insurance", whether primary, excess, contingent or on any other basis, that is available to the additional insured for a loss we cover under this endorsement. However, if the "written contract requiring insurance" specifically requires that this insurance apply on a primary basis or a primary and non-contributory basis, this insurance is primary to 'other insurance" available to the additional insured which covers that person or organization as a named insured for such loss, and we will not share with that "other insurance". But the insurance provided to the additional insured by this endorsement still is excess over any valid and collectible 'other in- surance", whether primary, excess, contingent or on any other basis, that is available to the addi- tional insured when that person or organization is an additional insured under such 'other insur- ance". 4. As a condition of coverage provided to the additional insured by this endorsement: a) The additional insured must give us written notice as soon as practicable of an "occur- rence" or an offense which may result in a claim. To the extent possible, such notice should include: -CG'D2 46 08 05 © 2005 The St. Paul Travel ers-Co mpanies, Inc. _Page 1 of 013597 COMMERCIAL GENERAL LIAb,,ITY L How, when and where the 'occurrence" or offense took place; ii. The names and addresses of any injured persons and witnesses; and iii. The nature and location of any injury or damage arising out of the 'occurrence" or offense. b) If a claim is made or "suit" is brought against the additional insured, the additional insured must: i. Immediately record the specifics of the claim or "suit" and the date received; and ii. Notify us as soon as practicable. The additional insured must see to it that we receive written notice of the claim or "suit" as soon as practicable_ c) The additional insured must immediately send us copies of all legal papers received in connection with the claim or "suit' cooperate with us in the investigation or settlement of the claim or defense against the "suit', and otherwise comply with all policy conditions. d) The additional insured must tender the de- fense and indemnity of any claim or "suit' to any provider of 'other insurance" which would cover the additional insured for a loss we cover under this endorsement. However, this condition does not affect whether the insur- ance provided to the additional insured by this endorsement is primary to 'other insur- ance" available to the additional insured which covers that person or organization as a named insured as described in paragraph 3. above. 5. The following definition is added to SECTION V. — DEFINITIONS: "Written contract requiring insurance" means that part of any written contract or agreement under which you are required to include a person or organization as an additional in- sured on this Coverage Part, provided that the "bodily injury" and "property damage" oc- curs and the "personal injury" is caused by an offense committed: a. After the signing and execution of the contract or agreement by you; b. While that part of the contract or agreement is in effect; and c. Before the end of the policy period: Page 2 of 2 02005 The St. Paul Travelers Companies, Inc. CG D2 46 08 05