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HomeMy WebLinkAboutJACOBS INVESTMENTS LLC - INSURANCE CERTIFICATE� ® R CERTIFICATE. -OF LIABILITY'INSURANCE. ..-oP.ID..xx F _ DATE (MM/DD/YYYY) 61/,2 /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). PRODUCERUUN NAME: LBN Insurance Agcy-Johnstown PHONE FAX A/C, No, Ezt : (A/C, No):, MAIL ADDRESS: 4848 Thompson Pkwy, Ste 200 Johnstown CO 80534 PRODUCECUSTOMERID#: COBOR-1 Phone:970-635-9400 Fax.:970-635-9401 INSURER(S) AFFORDING COVERAGE NAIC# INSURED INSURERA: Travelers Companies Jacobs Investments, LLC Colorado Boring, LLC INSURERB: Pinnacol Assurance 41190 INSURERC: Northern Lights Leasing, LLC 812 Queens court 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 PAIN CLAIMS. L TYPE OF INSURANCE 'LITR INSR WVD POLICY NUMBER (MM/DD/YYYY) (MM/DD/YYYY) LIMITS A GENERAL LIABILITY X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE ❑X OCCUR 08/01/10 08/01/11 EACH OCCURRENCE $ 1,000,000 PREMISES(Eaoccurrence) $300,000 MED EXP (Any one person) $ 10,000 PERSONAL BADVINJURY $1,000,000 GENERAL AGGREGATE s2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER:. POLICY g PJECTRO LOC PRODUCTS - COMP/OP AGG s2,000,000 $ A AUTOMOBILE LIABILITY ANY AUTO,. ALL OWNED AUTOS SCHEDULED AUTOS HIRED AUTOS NON -OWNED AUTOS - 08/01/10 08/01/11 COMBINED SINGLE LIMIT (Ea accident) $ 1,000,000 X BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ PROPERTY DAMAGE - -,." (Per accident) $ - -- X X $ A UMBRELLA LIAB EXCESS LIAB IX OCCUR CLAIMS -MADE 08/01/10 08/01/11 EACH OCCURRENCE $ 5,000,000 AGGREGATE $ 5,000,000 DEDUCTIBLE RETENTION $ 10,000 $ X $ B WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y / N ANY PF.OPRIETOR/PART,4ER/EXECUTIVf -� OFFICER/MEMBER EXCLUDED? U (Mandatory In NH) If yes, describe under DESCRIPTION OF OPERATIONS below /A 4021687 -BLANKET WAZ73B OF SUBROCA - _ 08/01/10 08/O1/.10- 08/01/11 OB/A1/11.-. X WC - XH. TORY LIMITS ER E,L.EACH-ACCIDENT-- - $ 1, 000, 000 E.L. DISEASE - EA EMPLOYEE $ 1, 0 0 0 , 0 0 0 E.L. DISEASE - POLICY LIMIT $ 1,.0 0 0, 0 0 0 A Inland Marine 08/01/10 08/01/11 Deductibl 500 Scheduled 1266500 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, If more space Is required) If required by written contract or written agreement, The City of Fort Collins and CDOT are included as additional insured for ongoing operations under General Liability. CERTIFICATE HOLDER CANCELLATION City of Fort Collins Purchasing 281 North College Ave Fort Collins CO 805220580 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE FORT - 01 I THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE ©1988-2009 ACORD CORPORATION. All rights reserved. ACORD 25 (2009/09) The ACORD name and logo are registered marks of ACORD