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Home My WebLink About102829 DON KEHN CONSTRUCTION INC - INSURANCE CERTIFICATE (4)client#: bzz10 BDONKEHN ACORDTM CERTIFICATE OF LIABILITY INSURANCE DA/30/10D/YYrr) PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Willis of Colorado, Inc. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE 720 South Colorado Boulevard HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Suite 60ON Denver, CO 80246 INSURERS AFFORDING COVERAGE NAIC # INSURED INSURER A: Zurich American Insurance 16535 Don Kehn Construction, Inc. INSURER B: Everest National Insurance Co. 10120 6550 SCR5 INSURER C: Pinnacol Assurance 41190 Fort Collins, CO 80528 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. INSR LTR NSR TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE DATE MM DD/YY POLICY EXPIRATION DATE MM DD LIMITS A GENERAL LIABILITY GLA5942579 11/01/09 11/01/10 EACH OCCURRENCE $1 00O 000 X COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTEDPREMISES (E. $300OOO MED EXP (Any one person) $5 000 CLAIMS MADE FXI OCCUR PERSONAL & ADV INJURY $1 000 000 X Ltd Pollution X AI# UGL1175BCW 3/07 GENERAL AGGREGATE $2 00O 000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP/OP AGG s2,000,000 POLICY-X] PROECT LOC J A AUTOMOBILE LIABILITY ANY AUTO GLA5942579 11/01/09 11/01/10 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) $ Ltd Pollkution GARAGE LIABILITY AUTO ONLY - EA ACCIDENT $ OTHER THAN EA ACC $ ANY AUTO $ AUTO ONLY: AGG B EXCESS/UMBRELLA LIABILITY X OCCUR F—ICLAIMS MADE 71CH000023091 11/01/09 11/01/10 EACH OCCURRENCE $2000000 AGGREGATE $2 00O 000 $ $ DEDUCTIBLE $ X RETENTION $ 1 O 000. C -WORKERS. COMPENSATION AIAM-__ _ __ 2093950 - ___ 10/01[W _ a=1d14. :.,... XX OR LIMITTATU , _ PR - EMPLOYERS' LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE E.L. EACH ACCIDENT $500 000 E.L. DISEASE - EA EMPLOYEE s500,000 OFFICER/MEMBER EXCLUDED? If yes, describe under SPECIAL PROVISIONS below E.L. DISEASE - POLICY LIMIT $500,000 OTHER DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES / EXCLUSIONS ADDED BY ENDORSEMENT / SPECIAL PROVISIONS - Project Description: Furnishing Asphalt The following are Additional Insureds as respects General Liability only if required by written contract and coverage applies only as respects (See Attached Descriptions) I M nULUCK City of Ft. Collins ATTN: Director of Purchasing & Risk Management P. O. Box 580 Ft. Collins, CO 80522-0580 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL '1n* 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 AUTHORIZED REPRESENTATIVE C✓ 6�u� • ALA? At.UKU LJ (LUUI/Utf) 1 of 3 #S720228/M720067 8MSTY 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 3 #S720228/M720067 AMS 25.3 (Z009/OS) 3 of 3 #5720228/M720067 Additional Insured — Automatic — .0--wners, Lessees Or ZURICH Contractors Policy No, Exp. Date of Pol. Eff. Date of End. Agency No. Addl. Prem. Retum Prem. THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. Named Insured: Address (including ZIP Code): This endorsement modifies insurance provided under the: Commercial General Liability Coverage Part A. Section II — Who Is -An Insured is amended to include as an insured any person or organization who you are re- quired to add as an additional insured on this policy under a written contract or written agreement. B. The insurance provided to the additional insured person or organization applies onlyto "bodily injury", "property damage" or "personal and advertising injury" covered under SECTION I - Coverage A - Bodily Injury And Prop- erty Damage Liability and Section I.- Coverage B - Personal IAnd Advertising Injury Liability, but only with respect to liability for "bodily injury "property damage" or "personal and advertising injury" caused, in whole or in . part, by; 1. Your acts or emissions; or 2; The acts or omissions of those.apting on your behalf; and resulting directly from: a. Your ongoing operations performed for the additional insured, which is the subject of the written contract or written agreement; or b._ "Your work" completed as included in the "products -completed operations hazard", performed fer the addi- tional insured, which is the,subject of the written contract or written' agreement. C. However, regardless of the provisions of paragraphs r'�. arid- . above: - 1. We will not extend any insurance coverage to any additional insured person or organization: a. That is not provided to you in this policy; or b. That is any broader coverage than you are required to provide to the additional insured person or organiza- tion in the written, contract or written agreement; and . 2. We will not provide Limits of Insurance to any additional insured person or organization that exceed the lower of: Ti T 1 c �ridPd to 1 1 this C l fi. The I imits ofInsurance pro y0L P. .1 pO..ICy; or b. The Limits of Insurance you are required to provide in the written contract oI- written agreement. Includes copyrighted material of Insurance Services Office; Inc., with its permission. U-GL-1 175-B CW (3/2007) Page 1 of-2