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HomeMy WebLinkAboutJACOBS INVESTMENTS LLC - INSURANCE CERTIFICATE (2)I- CERTIFICATE•.OF- L-•IABILITY-INSURANCE-,--- OP ID KK . DATE (MM/DD/YYYY) 08/02/10 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 TMIAM NAME: LBN Insurance Agcy-Johnstown PHONE FAX A/C, No, Exe : (a/c, No): ADDRESS: 4848 Thompson Pkwy, Ste 200 PRODUCE R CU"OMERID#: COBOR-1 Johnstown CO 80534 INSURER(S) AFFORDING COVERAGE NAIC# Phone:970-635-9400 FaX:970-635-9401 INSURED' - INSURER A: Travelers Companies Jacobs Investments, LLC Colorado Boring, LLC INSURER B: Pinnacol Assurance 41190 INSURERC: Northern Lights Leasing, LLC 812 Queens Court Fort Collins CO 80525 INSURERD: 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) (MMIDD/YYYY) LIMITS A GENERAL LIABILITY X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE I —XI OCCUR 0075R25A 08/01/10 08/01/11 EACH OCCURRENCE $ 1,000,000 (EaOccurrence) $300,000 -PREMISES MED EXP (Any one person) $ 10,000 PERSONAL BADVINJURY $ 1,000,006 GENERAL AGGREGATE s2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: POLICY g PRO LOC JECT PRODUCTS - COMP/OP AGG $ 2 , 0 0 0 , 0 0 0 $ A AUTOMOBILE LIABILITY ANY AUTO ALL OWNED AUTOS, SCHEDULED AUTOS HIREDAUTOS NON -OWNED AUTOS - - - 0075R25A 08/01/10 08/01/11 COMBINED SINGLE LIMIT (Ea accident) $ 11000,000 X BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ PROPERTY DAMAGE (Per accident) $ - X X $ A UMBRELLA LIAB EXCESS LAB X OCCUR CLAIMS -MADE 0075R25A 08/01/10 08/01/11 EACH OCCURRENCE $ 5, 000, 000 AGGREGATE $ 5, 0 0 0, 0 0 0 DEDUCTIBLE RETENTION $ 10,000 $ X $ B WORKERS COMPENSATION AND EMPLOYERS' Y/-N ANY PROPRIETOR/PARTNER/EXECUTIV M OFFICER/MEMBER EXCLUDED? U (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below _. _. / A '_ti 4021687 ur TT-WAxan_na_SUBROGA_ _ _ 08/O1/10. 08/01/10 ._ 08/O1/11 08,/O1/11 X - 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 A Inland Marine 0075R25A 08/01/10 08/01/11 Deductibl 500 Scheduled 1266500 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Attach ACORD 1Ole 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 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. City of Fort Collins AUTHORIZED REPRESENTATIVE Purchasing 281 North College Ave /J Fort Collins CO 805220580 ©1988-2009 ACORD CORPORATION. All rights reserved. ACORD 25 (2009/09) The ACORD name and logo are registered marks of ACORD