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HomeMy WebLinkAbout103265 HAISTON OIL COMPANY INC - INSURANCE CERTIFICATE (6)�® CERTIFICATE OF LIABILITY INSURANCE OP ID KH DATEIMMIDDYYYV) 06/29/10 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. 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). PRODUCER NAME: PH NE ac, No, EXt: INC, No): LBN Insurance Agcy-Johnstown ADDRESS:PRODUCER 4848 Thompson Pkwy, Ste 200 CUSTOMER ID e: HAIST-1 _ Johnstown CO 80534 Phone:970-635-9400 Fax:970-635-9401 INSURER(S) AFFORDING COVERAGE NAICM INSURED INSURERA: Nationwide Agribusiness Ins Cc 28223 INSURER B: Haiston oil Company, Inc Jeff Haiston 335 S Summit View Dr INSURER C: Fort Collins CO 80524 INSURER D: INSURER E : INSURER F : COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT 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 CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAYBE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BVPAID CLAIMS. LTRIN5R TYPE OF INSURANCE INSR WVD POLICY NUMBER (MMIDD/YY ) (MM/DWYYYY) LIMITS A GENERAL LIABILITY X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE I —XI OCCUR CPP 107224A 07/01/10 02/01/11 EACH OCCURRENCE $1000000 PREMISES (Ea occurrence)$100000 MED EXP(Any one person) $ 5000 PERSONAL &ADV INJURY s1000000 GENERAL AGGREGATE $ 2000000 GEN'L AGGREGATE LIMIT APPLIES PER: X POLICY JE°T Loc PRODUCTS-COMP/OP AGO E 2000000 Elhop Ben. $ 1000000 A AUTOMOBILE LIABILITY ANYAUTO ALL OWNED AUTOS SCHEDULED AUTOS HIREDAUTOS NON -OWNED AUTOS broad auto pollut CA 107224A MCS 90 CA9948 07/01/10 02/01/11 COMBINED SINGLE LIMIT (Ea accident) $1000000 X BODILVINJURN(Pe, person) $ BODILY INJURY (Par accident) $ PROPERTY DAMAGE (Per accident) $ X X S X $ A UMBRELLA LIAB EXCESS LIAB X OCCUR CLAIMS -MADE CD 107224A 07/01/10 02/01/11 EACH OCCURRENCE s 1000000 AGGREGATE $1000000 DEDUCTIBLE I RETENTION $ 10,000 $ X $ COMPENSATION AND EMPLOYERS'LIABILITY Y/N ANY PROPRIETOR/PARTNER/EXECUTIVF� OFFICERIMEMBER EXCLUDED? U (Mandatory In NH) If Yes, describe under DESCRIPTION OF OPERATIONS below /A NIA TATWORKERS ER TORN LIMITS JU E.L. EACH ACCIDENT $ E.L. DISEASE - EA EMPLOYEE _ $ E.L. DISEASE -POLICY LIMIT E DESCRIPTION OF OPERATIONS / LOCATIONS I VEHICLES (AtlacN ACORD 101, AOCISonal Ri medal SeheCule, If mom space is required) r POTIPIr ATIP urn nFR CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE CITYFTC I THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. City of Fort Collins AUTHORIZED REPRESENTATIVE Jim Hime PO Box 580 _ ___ _ • ; • eT�l:73e1:711 ACORD 26 (2009/09) The ACORD name and logo are registered marks of ACORD