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HomeMy WebLinkAboutTHE BURRITO DREAM - INSURANCE CERTIFICATE (4)06/07/2010 16:51 9704956769 INS SPECIALTIES LTD PAGE 02 NATIONWIDE MUTUAL INSURANCE COMPANY 1100 LOCUST ST DEPT 1100 DES MOINES,IA 50391.2000 COMMERCIAL GENERAL LIABILITY DECLARATIONS Policy Number: ACP GLO 7504353659 Named Insured: CHRISTOPHER LARSON - DBA THE BURRITO DREAM Address: 610 LOCUST ST FORT COLLINS CO 80524-3404 28407 NEW BUSINESS Agent: INSURANCE SPECIALTIES LTD 05-28401-001 CSC Address: FORT COLLINS CO 80524 PRODUCER: INSURANCE SPECIALTIES LTD Policy Period: From 01130/10 to 01f30/11 12:01 A.M. standard time at the address of the named insured as stated herein. 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. LIMITS OF INSURANCE GENERAL AGGREGATE LIMIT (other than Products -completed operations) 21000,000 PRODUCTS -COMPLETED OPERATIONS AGGREGATE LIMIT 2, 000, 000 PERSONAL AND ADVERTISING INJURY LIMIT 11000,000 000 EACH OCCURRENCE LIMIT 1, 000, 000 DAMAGE TO PREMISES RENTED TO YOU LIMIT (any one premises) 100, 000 MEDICAL EXPENSE LIMIT (any one person) I 5,000 Retroactive Dale (CG0002 only) The Named Insured is: LIMITED LIABILITY CO Business of the Named Insured is. BURRITO CART Audit Period: ANNUAL ENDORSEMENTS ATTACHED TO THIS POLICY SEE COMMERCIAL GENERAL LIABILITY FORMS AND ENDORSEMENTS SCHEDULE Replacement or Renewal Number GL-D (10-98) DIRECT BILL LML2 10064 TOTAL ADVANCE PREMIUM $ 600.a0m Countersigned By Authorized Reprasentativa Ceram. 1300 AGENT COPY ACP GLO 7504353659 $72746691 75 0023721 06/07/2010 16:51 9704956769 INS SPECIALTIES LTD PAGE 03 NATIONWIDE MUTUAL INSURANCE COMPANY 1100 LOCUST ST DEPT 1100 DES MOINES, IA 50391-2000 COMMERCIAL GENERAL LIABILITY SCHEDULE Policy Number: ACP GLO 7504353659 Item No., Location Code Premium Rates Advance Premium and Description I No, Basis of Hazards OTHER I PR/CO OTHER PR/CO 001A CO-502 11162 GROSS SALES PER THOUSAND CONCESSIONAIRES 30,000 8.352 $251 PRODUCTS -COMPLETED OPERATIONS ARE SUBJECT TO THE GENERAL AGGREGATE LIMIT 610 LOCUST ST FORT COLLINS C0805243404 MINIMUM PREMIUM ADJUSTMENT $349 Total Advance Other and PR/CO $600 TOTAL ADVANCE PREMIUM $600MIN NOTE: For classes based on payroll each Executive Officer, Sole Proprietor or Partner may be subject to a fixed amount. GL-DS (12.93) DIRECT BILL LML2 10054 AGENT COPY ACP GLO 7504353652 87274889t 75 0023722 06/07/2010 16:51 9704956769 INS SPECIALTIES LTD PAGE 04 NATIONWIDE MUTUAL INSURANCE COMPANY 1100 LOCUST ST DEPT 11 DES MOINES,IA 50391.2000 COMMERCIAL GENERAL LIABILITY FORMS AND ENDORSEMENTS Number: ACP GLO 7504353659 Period: From 01f30110 To 01/30/11 Named Insured: CHRISTOPHER LARSON - DBA Form Date Title CG0001 1207 COMMERCIAL GENERAL LIABILITY COVERAGE FORM CG0068 0500 RECORDING AND DISTRIBUTION OF MATERIAL OR INFORMATION IN VIOLATION OF LAW EXCL CG2147 1207 EMPLOYMENT - RELATED PRACTICES EXCLUSION CG2167 1204 FUNGI OR BACTERIA EXCLUSION CG2170 0108 CAP ON LOSSES FROM CERTIFIED ACTS OF TERRORISM CG7023 1096 EXCL-ASBESTOS, ELECTRO-MAGNETIC RADIATION, LEAD AND RADON CG7033 0393 TWO OR MORE COVERAGE FORMS OR POLICIES ISSUED BY US GL2199 0600 EXCLUSION - SUBSIDENCE OF LAND IL0017 1198 COMMON POLICY CONDITIONS IL0021 0908 NUCLEAR ENERGY LIABILITY EXCLUSION IL0228 0907 COLORADO CHANGES - CANCELLATION AND NONRENEWAL 13614 1185 SPECIAL CONTINUATION PROVISfON IMPORTANT NOTICES IN7320 0305 NOTICE TO POLICYHOLDERS RESTRICTIONS AND CLARIFICATION OF COVERAGE IN7374 0706 NOTICE TO POLICYHOLDERS RESTRICTIONS AND CLARIFICATION OF COV. MOBILE EQUIP GLDF (02.93) DIRECT BILL LML2 10054 AGENT COPY ACP OLD 7504333659 872148691 75 0023723 06/07/2010 16:51 9704956769 INS SPECIALTIES LTD PAGE 05 POLICY NUMBER: COMMERCIAL GENERAL LIABILITY CG 20 12 05 09 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - STATE OR GOVERNMENTAL AGENCY OR SUBDIVISION OR POLITICAL SUBDIVISION - PERMITS OR AUTHORIZATIONS This endorsement modifies insurance provided under the fallowing: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE State Or Governmental Agency Or Subdivision Or Political Subdivision: CITY OF FORT COLLINS DEPT OF FINANCE PO BOX "0 FORT COLLINS, CO s0522 Section II — Who Is An Insured Is amended to in- clude as an insured any state or governmental agency or subdivision or political subdivision shown in the Schedule, subject to the following provisions: 1. This Insurance applies only with respect to opera- tions performed by you or on your behalf for which the state or governmental agency or subdivision or political subdivision has issued a permit or au- thorization. 2. This Insurance does not apply to: a. "Bodily injury", "property damage" or "personal and advertising injury" arising out of operations performed for the federal government, state or municipality; or b. "Bodily injury" or "property damage" included within the 'products -completed operations hazard". All terms and conditions of this policy apply unless modified by this endorsement. CG 20 12 05 09 © Insurance Services Office. Inc., 2008 Page 1 of 1 ACP GLO 7504393959 LML2 10154 AGENT COPY 75 0024339