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HomeMy WebLinkAboutDOHN CONSTRUCTION INC - INSURANCE CERTIFICATE (2)Ro® CERTIFICATE OF LIABILITY INSURANCE. OPIo sL DATE(MM/DD/YY.0 06/10/10 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: LBN Insurance Agcy-Johns town PHONE FAX ac, No, Ext : (A/C, No): ADDRESS: 4848 Thompson Pkwy, Ste 200 PRODUCER CUSTOMER ID#: " DO HNC-2 _ Johnstown CO 80534 Phone:970-635-9400 FaX:970-635-9401 INSURER(S) AFFORDING COVERAGE NAIC# INSURED INSURER A: Employers Mutual Dohn Construction, Inc. DCI Residential, LLC INSURERB: Pinnacol Assurance, 41190 INSURERC: 2642 Midpoint Drive Fort Collins CO 80525 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 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. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. LTR TYPE OF INSURANCE INSR WVD POLICY NUMBER (MM/DD/YYYY) (MM/DD/YYYY) LIMITS A GENERAL LIABILITY X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE ❑X OCCUR X Blanket Addr 1 Ins 1D57255 10/01/09 10/01/10 EACH OCCURRENCE $ 1, 0 0 0, 0 0 0 PREMISES (Eaoccurrence) $ 100,000 MED EXP (Any one person) $ 5,000 PERSONAL & ADV INJURY $ 1, 000, 000 X Blanket Waiver AGGREGATE s2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: 17 POLICY X PRO LOC JECT UCTS - COMP/OP AGG $ 2,000,000 FGENERAL $ A AUTOMOBILE LIABILITY ANY AUTO ALL OWNED AUTOS SCHEDULED AUTOS HIRED AUTOS NON -OWNED AUTOS 1Z57255 10/01/09 - - - -- 10/01/10 - INED SINGLE LIMIT cident) $ 1 , 0 0 0 , 0 0 0 X BODILY INJURY (Per person) - $ BODILY INJURY (Per accident) $ PROPERTY DAMAGE (Per accident) $ X X $ $ A UMBRELLA LIAB EXCESS LIAB X OCCUR CLAIMS -MADE 1J57255 10/01/09 10/01/10 EACH OCCURRENCE $ 10, 000, 000 AGGREGATE $ 10 , 0 0 0 , 0 0 0 DEDUCTIBLE RETENTION $ $ $ B WORKERS COMPENSATION AND EMPLOYERS' LIABILITY _.. ,. _Y /,N ANY PROPRIETOR/PARTNER/EXECUTIV OFFICER/MEMBER EXCLUDED? (Mandatory In NH) If es, describe under DESCRIPTION OF OPERATIONS below / A 3055407 ,. B::AxxEr WAIVER' OF 'SUBRO 07/01/10 07/01/11 X TORY LIMITS ER E.L. EACH ACCIDENT - $ 1,000,000 E.L. DISEASE - EA EMPLOYEE $ 1,000,000 E.L. DISEASE - POLICY LIMIT $ 1,000,000 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space Is required) RE: Lincoln Center Addition and Renovations Bid No. 7136 (See holder notes for additional wording) CERTIFICATE HOLDER CANCELLATION City of Fort Collins Purchasing Division 2nd Floor 215 North Mason Street fort Collins CO 80524 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE CITYOFC I THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. REPRESENTATIVE ©1988-2009 ACORD CORPORATION. All rights reserved. ACORD 25 (2009/09) The ACORD name and logo are registered marks of ACORD No Text