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Home My WebLink About133159 PAUL DAVIS RESTORATION - INSURANCE CERTIFICATE5/27/2010 19:11 Remote ID Imprint ID ❑ 2/3 ACORQ� CERTIFICATE 4F LIABILITY INSURANCE 5/27 MID°'YY, OS/27/10 PRODUCER 1-303-534-4567 FALTER ERTIFICATE IS ISSUED AS A MATTER OF INFORMATION IMA of Colorado, Inc. AND CONFERS NO RIGHTS UPON THE CERTIFICATE R. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR 1550 17th Street THE COVERAGE AFFORDED BY THE POLICIES BELOW. Suite 600 Denver, CO 80202 INSURERS AFFORDING COVERAGE INSURED INSURER A:Pinnacol Assurance OnePoint Employers Solutions, LLC and OnePoint HRO LLC INSURER & 5670 Greenwood Plaza Blvd., #200 INSURERC: Englewood, CO 80111 INSURERD: 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. INSR TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATIONJJIL LIMITS GENERAL LIABILITY EACH OCCURRENCE $ FIRE DAMAGE (Any one fire) $ COMMERCIAL GENERAL LIABILITY MED EXP (Any one person) $ CLAIMS MADE OCCUR PERSONAL & ADV INJURY $ GENERAL AGGREGATE $ GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP/OP AGG S POLICY PRO - AUTOMOBILE AUTOMOBILE LIABILITY ANY AUTO COMBINED SINGLE LIMIT (Ea accident) $ BODILY INJURY (Per peen) $ 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 LIABILITY EACH OCCURRENCE $ AGGREGATE $ OCCUR CLAIMS MADE $ DEDUCTIBLE $ RETENTION $ A WORKERS COMPENSATION AND EMPLOYERS' LIABILITY 4028674 05/01/10 05/01/11 X TORYLMITS ER E.L. EACH ACCIDENT $ 100,000 E.L. DISEASE - EA EMPLOYE $ 100,000 E.L. DISEASE -POLICY LIMIT $ 500,000 OTHER b b E DESCRIPTION OF OPERATIONSILOCATIONSIVEHICLES/EXCLUSIONS ADDED BY ENDORSEMENTISPECIAL PROVISIONS This Certificate shows that Legacy Corporation DBA Paul Davis Restoration of Northern Colorado at 309 Lincoln Street, Fort Collins, CO 80524 is covered under the Workers Compensation Policy issued to OnePoint Employer Solutions LLC and OnePoint HRO LLC. am I I ADDITIONAL City of Fort Collins and Poudre Fire Authority Att: Ed Bonnette PO Box 580 Ft Collins , CO 80522 USA 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 IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER ITS AGENTS OR REPRESENTATIVES. AUTHORIZED REPRESENTATIVE J ACORD 25-S (7/97) junger 15959923 Certificate Delivery by CertificatesNow - www.ConfirmNet.com - 877.669.8600 OACORD CORPORATION 1 5/27/2010 19:11 Remote ID Imprint ID D 3/3 111e�` 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.