HomeMy WebLinkAbout107048 QWEST GOVERNMENT SERVICES INC - INSURANCE CERTIFICATEA� �P CERTIFICATE OF LIABILITY INSURANCE
DATE(MM/DD/YYYY)
„/, 7I2010
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
Marsh USA, Inc.
1301 5th Avenue, Suite 1900
CONTACT
NAME:
PHONE FA
A/C No Ex A/C No):
E-MAIL
Seattle, WA 98101
Attn: Kathy Hand 206 214-3119 Fax: 206 214-3483
PRODUCER
'
CUSTOMER ID M
INSURERS AFFORDING COVERAGE
NAIC #
100429-OGS-GAW-10-11 kbh cunt none
INSURED
INSURER A : National Union Fire Ins Cc Pittsburgh PA
19445
QWEST GOVERNMENT SERVICES, INC.
1801 CALIFORNIA STREET, SUITE 1150
INSURER B Insurance Company Of The State Of PA
19429
INSURER C :
DENVER, CO 80202
INSURER D :
INSURER E :
INSURER F :
COVERAGES CERTIFICATE NUMBER: SEA-001642066-07 REVISION NUMBER: 17
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.
INSR
LTR
TYPE OF INSURANCE
ADDL
SUBR
POLICY NUMBER
POLICY EFF
MM/DD/YYYY
POLICY EXP
MM/DDIYYYY
LIMITS
A
GENERAL LIABILITY
X
GL4360920
10/01/2010
10/01/2011
EACH OCCURRENCE
$ 1,000,000
X COMMERCIAL GENERAL LIABILITY
DAMAGE TO RENTED
PREMISES Ea occurrence
$ 1,000,000
CLAIMS -MADE � OCCUR
MED EXP (Any one person)
$ 10,000
PERSONAL & ADV INJURY
$ 1,000,000
GENERAL AGGREGATE
$ 2,000,000
GEN'L AGGREGATE LIMIT APPLIES PER:
PRODUCTS - COMP/OP AGG
$ 2,000,000
POLICY PRO El LOC
$
A
AUTOMOBILE
LIABILITY
CA3976620 (AOS)
10/01/2010
10/01/2011
COMBINED SINGLE LIMIT
$ 2,000,000
A
X
CA3976621 (CT)
10/01/2010
10/01/2011
(Ea accident)
BODILY INJURY (Per person)
$
A
X
ANY AUTO
CA3976622 (MA)
10/01/2010
10/01/2011
BODILY INJURY (Per accident)
$
A
ALL OWNED AUTOS
CA3976623 (VA)
10/01/2010
10/01/2011
SCHEDULED AUTOS
PROPERTY DAMAGE
X
HIRED AUTOS
(Per accident)
$
X
NON -OWNED AUTOS
$
X
SELF -INSURED FOR APD
$
UMBRELLA LIAB
HCLAIMS-MADE
OCCUR
EACH OCCURRENCE
$
AGGREGATE
$
EXCESS LIAB
DEDUCTIBLE
$
$
RETENTION $
B
WORKERS COMPENSATION
WCO26149624 (ADS)
10/01/2010
10/01/2011
X I WC STATU- I OTH-
AND EMPLOYERS' LIABILITY
E.L. EACH ACCIDENT
$ 1,000,000
B
a ANY PROPRIETOR/PARTNER/EXECUTIVE
WCO26149625 (CA)
10/01/2010
10/01/2011
B
OFFICER/MEMBER EXCLUDED?
(Mandatory in NH)
N /A
WCO26149626 FL
( )
10/01I2010
,0/01/2011
E.L. DISEASE - EA EMPLOYE
$ 1,000,000
B
If yes, describe under
DESCRIPTION OF OPERATIONS below
WCO26149627 T
(X)
10/01/2010
10/01/2011
E.L. DISEASE - POLICY LIMIT
$ 1,000,000
A
Workers' Compensation/EL
WCO26149628 (MA ND OH WI WY)
10/0112010
10/01/2011
Each Acc/Emp/Policy Limit $1,000,000
A
XS Workers' Compensation/EL
XWC1192341 (WA)
10/01/2010
10/01/2011
Excess of $1,000,000 SIR $1,000.000
DESCRIPTION OF OPERATIONS I LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required)
RE: P871 RENEWAL. SERVICE AGREEMENT TO PROVIDE MAINTENANCE OF EQUIPMENT & SOFTWARE FOR CUSTOMER -PROVIDED EQUIPMENT AT VARIOUS
BUILDING LOCATIONS, THE CITY OF FORT COLLINS, ITS OFFICERS, AGENTS & EMPLOYEES ARE ADDITIONAL INSUREDS PER THE GENERAL LIABILITY BLANKET
ADDITIONAL INSURED ENDORSEMENT AS RESPECTS THEIR INTEREST IN THE OPERATIONS OF THE NAMED INSURED AS REQUIRED BY WRITTEN CONTRACT.
k;LK I IFIL;A I t_ MULUtK
CITY OF FORT COLLINS PURCHASING
215 NORTH MASON, 2ND FLOOR
P.O. BOX 580
FORT COLLINS, CO 80522
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
AUTHORIZED REPRESENTATIVE
of Marsh USA Inc.
Cheryll L. Koch
01988-2009 ACORD CORPORATION. All rights reserved.
ACORD 25 (2009/09) The ACORD name and logo are registered marks of ACORD