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INSIN2
ACORD-CERTIFICATE OF LIABILITY INSURANCE
DATE
08/30/2010YYV)
PRODUCER
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
Flood & Peterson Ins., Inc.
Corporate Mailing Address:
P g
ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
P. O. Box 578
Greeley, CO 80632
INSURERS AFFORDING COVERAGE
NAIC #
INSURED
In -Situ, Inc.
221 E Lincoln Ave
Fort Collins, CO 80524
INSURER A: OneBeacon
INSURER B: Pinnacol Assurance
INSURER C:
INSURER D:
INSURER E:
COVERAGES
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. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
LTR
NSR
TYPE OF INSURANCE
POLICY NUMBER
POLICY EFFECTIVE
DATE MM/DD/YY
POLICY EXPIRATION
DATE MM/DD/VY
LIMITS
A
GENERAL LIABILITY
7110108440002
09/01/10
09/01/11
EACH OCCURRENCE
$ j 000 000
COMMERCIAL GENERAL LIABILITY
DAMAGE TO RENTED
MISor
PRE ES (E 'currence)
$500000
CLAIMS MADE OCCUR
MED EXP (Any one person)
$1 O 000
PERSONAL & ADV INJURY
$1 OOO 000
GENERAL AGGREGATE
s2,000,000
GEN'L AGGREGATE LIMIT APPLIES PER:
PRODUCTS - COMP/OP AGG
s2,000,000
POLICY PROJECT LOC
A
AUTOMOBILE
LIABILITY
ANY AUTO
7110108440002
09/01/10
09/01/11
COMBINED SINGLE LIMIT
(Ea accident)
$1,000,000
X
BODILY INJURY
(Per person)
$
ALL OWNED AUTOS
SCHEDULED AUTOS
X
BODILY INJURY
(Per accident)
$
HIRED AUTOS
NON -OWNED AUTOS
X
X
PROPERTY DAMAGE
(Per accident)
$
Drive Other Car
GARAGE LIABILITY
AUTO ONLY - EA ACCIDENT
$
OTHER THAN EA ACC
$
ANY AUTO
$
AUTO ONLY: AGG
A
EXCESS/UMBRELLA LIABILITY
7110108440002
09/01/10
09/01/11
EACH OCCURRENCE
$5 OOO OOO
X OCCUR CLAIMS MADE
AGGREGATE
s5,000,000
$
DEDUCTIBLE
$
X RETENTION $ 0
B
WORKERS COMPENSATION AND
4126084
09/01/10
09/01/11
WC STATU- O FIR
EMPLOYERS' LIABILITY
ANY PROPRIETOR/PARTNER/EXECUTIVE
E.L. EACH ACCIDENT
$1 000 000
E.L. DISEASE - EA EMPLOYEE
$1 000 000
OFFICER/MEMBER EXCLUDED?
If yes, descunder
SPECIAL PrROVISIONS below
E.L. DISEASE - POLICY LIMIT
$1 000 000
OTHER
DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES / EXCLUSIONS ADDED BY ENDORSEMENT / SPECIAL PROVISIONS
RE: 221 E. Lincoln Ave Ft. Collins, CO
Coverage is for replacement cost, Special Form, $5,000 Deductible.
ua
City of Fort Collins
300 Laporte Ave
Fort Collins, CO 80526
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION
DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL _ n DAYS WRITTEN
NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL
IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR
REPRESENTATIVES.
AUTHORIZED REPRESENTATIVE
q� �C�_.
ACORD 25 (2001/08) 1 of 2 #S556608/M556594 KLB 0 ACORD CORPORATION 1988
IMPORTANT
If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. A statement
on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s).
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).
DISCLAIMER
The Certificate of Insurance on the reverse side of this form does not constitute a contract between
the issuing insurer(s), authorized representative or producer, and the certificate holder, nor does it
affirmatively or negatively amend, extend or alter the coverage afforded by the policies listed thereon.
ACORD 25-S (2001/08) 2 of 2 #S556608/M556594