HomeMy WebLinkAbout460607 CAMELOT CLEANERS - INSURANCE CERTIFICATE09-13-10;15:23 2216707 # 1/ 2
ACORD CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY)
09/13/2010
PRODUCER (970) 377-0638 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
Squires Insurance Solutions LLC ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
4025 Automation Way ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
Bldg B, Suite 4
Fort Collins CO 80525- INSURERS AFFORDING COVERAGE NAIC #
INSURED INSURER A: Hart ford Casualty Ins Co
Dean Archambo, dba INSURER B: Sentinel Insurance Co
Camelot Cleaners INSURER C: Pinnacol Assurance
2649 E Mulberry St, Ste 11A INSURERD:
CAVFRAnPq
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
ADD'
INSRL
TYPE OF INSURANCE
POLICY NUMBER
POLICY EFFECTIVE
DATE (MWDDIYY)
POLICY EXPIRATION
DATE (MMIDDIYY)
LIMITS
A
X
GENERAL LIABILITY
34 SBA IS9881
08/29/2010
08/29/2011
EACH OCCURRENCE
$ 1,000,000
PREMISES Ea C.our,Dence
$ 300,000
X COMMERCIAL GENERAL LIABILITY
CLAIMS MADE FKOCCUR
/ /
/ /
MED EXP (Any one person)
$ 10, 000
PERSONAL B ADV INJURY
$ 1,000,000
GENERAL AGGREGATE
S 2,000,000
GEML AGGREGATE LIMIT APPLIES PER:
PRODUCTS - COMP/OP AGG
$ 2,000,000
1-1 POLICY JECT LOC
/ /
/ /
BPLI
5,000
B
X
AUTOMOBILE
LIABILITY
ANY AUTO
34 UEC JJ784
08/29/2010
08/29/2011
COMBINED SINGLE LIMIT
(Ea accident)
$ 1,000,000
BODILY INJURY
(Per person)
$
X
ALL OWNED AUTOS
SCHEDULED AUTOS
/ /
/ /
BODILY INJURY
(Per accident)
$
X
X
HIRED AUTOS
NON -OWNED AUTOS
/ /
/ /
PROPERTY DAMAGE
(Per accdent)
$
GARAGE LIABILITY
AUTO ONLY - EA ACCIDENT
$
ANY AUTO
/ /
/ /
OTHERTHAN EA ACC
$
$
AUTO ONLY: AGG
A
X
EXCESS/UMBR ELLA LIABI LITY
X OCCUR CLAIMS MADE
34 SBA I39881
08/29/2010
08/29/2011
EACH OCCURRENCE
$
AGGREGATE
$
DMBRL
S 2,000,000
$
X DEDUCTIBLE 10,000
/ /
/ %
RETENTION $
C
WORKERS COMPENSATION AND
EMPLOYERS' LIABILITY
ANY PROPRIETOR/PARTNEFVEXECUTIVE
ANY
4142182
08/29/2010
09/01/2011
g �} OR -
X WC LIMITS OER
ITOR
E.L. EACH ACCIDENT
$ 100,000
E.L. DISEASE - EA EMPLOYEEI
$ 100,000
OFFICER/MEMBER EXCLUDED?
II yes, describe under
SPECIAL PROVISIONS below
/ /
/ / _
E.L. DISEASE -POLICY LIMIT I
S 500,000
A
OTHER BOppR
34 SBA IS9881
08/29/2010
08/29/2011
DESCRIPTION OF OPERATIONSILOCAnONSNEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS
Certificate Holder is listed as Additional Insured on the policy as per policy forms and conditions.
t;tH.I IFIt;A I It FMULUtH' t;ANUtLLA I IUN
(970) 221-6775 (970) 221-6707 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE
Purchasing Department EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL
10 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT. BUT
City of Fort Collins FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE
PO BOX 580 INSURER, ITS AGENTS OR REPRESENTATIVES.
AUTHORIZED REPRESENTATIVE _
Fort Collins CO 80527- aie-
ACORD 25 (2001/08) 0 ACORD CORPORATION 1988
INS025 (0108).06 Page 1 of 2
09-13-10;15:23 2216707 # 2/ 2
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 (2001106)
INS025 tofoat.os AMS Page 2 of 2