Loading...
HomeMy WebLinkAbout455706 STOLFUS & ASSOCIATES INC - INSURANCE CERTIFICATE (3)'4llk. ® CERTIFICATE OF LIABILITY INSURANCE Fil/2/2010`"""' 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 Van Gilder Insurance Cor p• 1515 Wynkoop, Suite 200 Denver CO 80202 CONTACT NAME: Dawn Gaba an PHONE FAX A/c No Ext:3Q3 8 7-.No):3_03-831-5295 E-MAIL ADDRESS: d abayan@vgic.com PRODUCER CUSTOMER ID#: STOASC INSURER(S) AFFORDING COVERAGE NAIC INSURED Stolfus & Associates, Inc. 5690 DTC Boulevard INSURER A: Hartford Insurance Company 0 INSURERB:XL Specialty Insurance Co. _ 0 INSURERC: Suite 101W INSURER D: Greenwood Village CO 80111 INSURER E : INSURER F : COVERAGES CERTIFICATE NUMBER: 2112387711 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. INSR LTR TYPE OF INSURANCE iADDL INSR SOBRi WVD POLICY NUMBER POLICY EFF MM/DD/YYYY POLICY EXP MM/DDIYYYY LIMITS A GENERAL LIABILITY Y Y 34SBWPD4904 10/1/2010 10/1/2011 EACH OCCURRENCE $1,000,000 X COMMERCIAL GENERAL LIABILITY DAMAGES ( RENTEDEa occurrence) $1, c00, 000 MED EXP (Anyone person) $10, 000 CLAIMS -MADE I X OCCUR PERSONAL &ADV INJURY $1, 000,000 GENERAL AGGREGATE $2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP/OP AGG $2,000,000 1-1 POLICY X I PRO- 17 LOC I $ A AUTOMOBILE LIABILITY Y Y 34SBWPD4904 10/1/2010 10/l/2011 COMBINED SINGLE LIMIT (Ea accident) $1, 000, 000 ANY AUTO BODILY INJURY (Per person) $ ALL OWNED AUTOS BODILY INJURY (Per accident) $ X SCHEDULED AUTOS HIRED AUTOS PROPERTY DAMAGE (Per accident) $ X NON -OWNED AUTOS $ $ A X UMBRELLA LIAB X OCCUR Y Y 34SBWPD4904 10/1/2010 10/1/2011 EACH OCCURRENCE $1, 000,000 AGGREGATE $1, 000,000 EXCESS LIAB CLAIMS -MADE DEDUCTIBLE $ $ X RETENTION 510, 000 I WORKERS COMPENSATION WC STATU- OTH- AND EMPLOYERS' LIABILITY YIN ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? ❑ N / A TORY LIMITS 1 _ER E.L. EACH ACCIDENT $ E.L. DISEASE - EA EMPLOYE $ (Mandatory in NH) If yes, describe under E.L. DISEASE - POLICY LIMIT 1 $ DESCRIPTION OF OPERATIONS below B Professional Liability IDPS9689446 10/1/2010 1c/1/2011 Per Claim $1, 000,000 Claims Made I Annual Aggregate $1, 000,000 DESCRIPTION OF OPERATIONS / LOCATIONS I VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required) If required by written contract or written agreement, the following provisions apply subject to the policy terms, conditions, limitations and exclusions: The Certificate Holder and Owner are included as Additional Insureds for ongoing and completed operations under General Liability; Automobile Liability; See Attached... t,rm I Iri%,A I t r1ULUrK I,AN1L tLLA I IUN City of Ft. Collins; Attn: John Stephen 250 North Mason 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 ©1988-2009 ACORD CORPORATION. All rights reserved. ACORD 25 (2009/09) The ACORD name and logo are registered marks of ACORD AGENCY Van Gilder Insurance Corp. POLICY NUMBER CARRIER ADDITIONAL REMARKS AGENCY CUSTOMER ID: STOASC LOC #: ADDITIONAL REMARKS SCHEDULE NAIC CODE NAMED INSURED Stolfus & Associates, Inc. 5690 DTC Boulevard Suite 101W Greenwood Village CO 80111 EFFECTIVE DATE: Page 1 of 1 THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, FORM NUMBER: 25 FORM TITLE:CERTIFICATE OF LIABILITY INSURANCE and Additional Insured under Umbrella / Excess Liability but only with respect to liability arising out of the Named Insured's work performed on behalf of the certificate holder and owner. This insurance will apply on a primary, non-contributory basis. A Blanket Waiver of Subrogation applies for General Liability, Automobile Liability and Umbrella/Excess Liability. Limited Contractual Liability is included. The Umbrella / Excess Liability policy provides excess coverage over the General Liability, Automobile Liability and Employers Liability. If required by written contract or written agreement, the City of Ft. Collins is included as Additional Insured for ongoing operations under General Liability. ACORD 101 (2008/01) © 2008 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD ,4` oRn® CERTIFICATE OF LIABILITY INSURANCE Fil/2/2010'YYY' 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 Van Gilder Insurance Corp. 1515 Wynkoop, Suite 200 Denver CO 80202 CONTACT NAME: Dawn Gaba an PHONE FAX _(A/C,No. E:t_303-_g_37-8524 SA/A/c No -_831,=52 5 E-MAIL ADDRESS: d aba an@v ic. com PRODUCER CUSTOMER ID#: STOASC INSURER(S) AFFORDING COVERAGE NAIC # --------- -------- INSURED INSURER A: Hartford Insurance _Company _ 0 Stolfus & Associates, Inc. 5690 DTC Boulevard INSURERB:XL Specialty Insurance CO. 0 INSURERC: --- ------ ---- Suite 101W INSURER D: Greenwood Village CO 80111 INSURER E : INSURER F : COVERAGES CERTIFICATE NUMBER:2057208319 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. NS INSR TYPE OF INSURANCE IADDL1SUBR INSR, WVD POLICY NUMBER POLICY EFF MM/DDIYYYY POLICY EXP I MM/DD/YYYY LIMITS A GENERAL LIABILITY X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE a OCCUR Y Y 34SBWPD4904 10/1/2010 (10/1/2011 EACH OCCURRENCE $1, 000, 000 DAMAGET RENTED PREMISES (Ea occurrence) $ 1, 000, 000 MED EXP (Any one person) $10, 000 PERSONAL & ADV INJURY $1, 000, 000 GENERAL AGGREGATE $2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: POLICY X PRO- JECT LOC PRODUCTS - COMP_/oPAGG $2,000,000 $ A AUTOMOBILE LIABILITY ANY AUTO ALL OWNED AUTOS SCHEDULED AUTOS HIRED AUTOS NON -OWNED AUTOS Y I IY I 34SBWPD4904 10/l/2010 10/l/2011 COMBINED SINGLE LIMIT (Ea accident) $1,000,000 BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ X X PROPERTY DAMAGE (Per accident) $ $ $ IX UMBRELLALIAB EXCESS LIABCLAIMS-MADE X OCCUR IY 34SBWPD4904 10/1/2010 10/1/2011 EACH OCCURRENCE $1,000,000 AGGY REGATE $1, 000,000 DEDUCTIBLE$ RETENTION S10, 000 $ WORKERS COMPENSATION I AND EMPLOYERS' LIABILITY Y / N ANY PROPRIETOR/PARTNER/EXECUTIVE ❑ OFFICER/MEMBER EXCLUDED? (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below N / A I I WC STATU- 1OTH- TORY LIMITS_ LER_ E.L. EACH ACCIDENT $ E.L. DISEASE - EA EMPLOYE $ E.L. DISEASE - POLICY LIMIT $ B �Professional LiabilityI Claims Made i I �D2S9689446 10/1/2010 10/1/2011 Per Claim $1,000,000 Annual Aggregate $1,000,000 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required) If required by written contract or written agreement, the following provisions apply subject to the policy terms, conditions, limitations and exclusions: The Certificate Holder and Owner are included as Additional Insureds for ongoing and completed operations under General Liability; Automobile Liability; See Attached... GtK111-IGAIt HULUtK GANCELLAIION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. City of Fort Collins Attn: Purchasing Division 215 North Mason Street, 2nd Floor - PO BOX AUTHORIZED REPRESENTATIVE For Fort Collins CO 80522 /e-a!'l @ 1988-2009 ACORD CORPORATION. All rights reserved. ACORD 25 (2009/09) The ACORD name and logo are registered marks of ACORD AC R i AGENCY CUSTOMER ID:STOASC LOC #: ADDITIONAL REMARKS SCHEDULE Page 1 of 1 AGENCY NAMED INSURED Van Gilder Insurance Corp. Stolfus & Associates, Inc. 5690 DTC Boulevard Suite 101W POLICY NUMBER Greenwood Village CO 80111 CARRIER NAIC CODE EFFECTIVE DATE: AUU THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, FORM NUMBER: 25 FORM TITLE: CERTIFICATE OF LIABILITY INSURANCE and Additional Insured under Umbrella / Excess Liability but only with respect to liability arising out of the Named Insured's work performed on behalf of the certificate holder and owner. This insurance will apply on a primary, non-contributory basis. A Blanket Waiver of Subrogation applies for General Liability, Automobile Liability and Umbrella/Excess Liability. Limited Contractual Liability is included. The Umbrella / Excess Liability policy provides excess coverage over the General Liability, Automobile Liability and Employers Liability. ACORD 101 (2008/01) © 2008 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD ACOOR o® CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDD IYYYY) 11/2/2010 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 Van Gilder Insurance Corp. 1515 Wynkoop, Suite 200 Denver CO 80202 CONTACT NAME: Dawn Gaba an PHONE FAX _(ac,No,Ext_3p3-837-a500 _Ian. L103=831=5.2-a5 E-MAIL ADDRESS: dgabayan@vgic.com ___ PRODUCER CUSTOMER ID #: STOASC INSURER(S) AFFORDING COVERAGE NAIC # INSURED INSURER A: Hartford Insurance Company 0 Stolfus & Associates, Inc. 5690 DTC Boulevard INSURERB:XL Specialty Insurance Co. 0 Suite 101W INSURERC: INSURER D: Greenwood Village CO 80111 INSURER E : INSURER F : COVERAGES CERTIFICATE NUMBER:1936178431 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. INSR LTR TYPE OF INSURANCE ADDGSUBR ( INSR WVD POLICY NUMBER POLICY EFF MM/DDIYYYY 1 POLICY EXP MM/DD LIMITS A GENERAL LIABILITY Y Y 34SBWPD4904 10/1/2010 I10/1/2011 EACH OCCURRENCE $1, 000, 000 X COMMERCIAL GENERAL LIABILITY I DAMAGE TO RENTED ( PREMISES Ea occurrence $l, 000, 000 CLAIMS -MADE rx-1 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/OPAGG $2,000,000 17 POLICY X PRO- LOC A AUTOMOBILE LIABILITY Y Y 34SBWPD4904 10/1/2010 10/1/2011 COMBINED SINGLE LIMIT (Ea accident) - $1, 000, 000 ANY AUTO BODILY INJURY (Per person) $ ALL OWNED AUTOS BODILY INJURY (Per accident) $ X SCHEDULED AUTOS HIRED AUTOS PROPERTY DAMAGE (Per accident) $ X NON -OWNED AUTOS ( $ $ A X UMBRELLA LIAB X OCCUR Y Y 34SBWPD4904 10/1/2010 10/l/2011 EACH OCCURRENCE $1, 000,000 I AGGREGATE $1, 000, 000 EXCESS LIAB CLAIMS -MADE DEDUCTIBLE $ $ X RETENTION $10, 000 I WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE � WC STATU- OTH- TO_RY LIMITS_ ER E.L. EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? N I A E.L. DISEASE - EA EMPLOYE $ (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT $ B Professional Liability DPS9689446 10/1/2010 10/1/2011 Per Claim $1, 000,000 Claims Made Annual Aggregate $1,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required) If required by written contract or written agreement, the following provisions apply subject to the policy terms, conditions, limitations and exclusions: The Certificate Holder and Owner are included as Additional Insureds for ongoing and completed operations under General Liability; Automobile Liability; See Attached... CERTIFICATE HOLDER CANCELLATION City of Fort Collins; Attn: Purchasing Division 215 North Mason Street, 2nd floor PO 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 ©1988-2009 ACORD CORPORATION. All rights reserved. ACORD 25 (2009/09) The ACORD name and logo are registered marks of ACORD AGENCY CUSTOMER ID: STOASC LOC #: AnnITIMIA1 RFMAPV_Q SrWl=nl11 F AGENCY NAMED INSURED Van Gilder Insurance Corp. Stolfus & Associates, Inc. 5690 DTC Boulevard POLICY NUMBER Suite 101W Greenwood Village CO 80111 CARRIER NAIC CODE EFFECTIVE DATE: WDITIONAL REMARKS I THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, (FORM NUMBER: 25 FORM TITLE: CERTIFICATE OF LIABILITY INSURANCE Paae , of , and Additional Insured under Umbrella / Excess Liability but only with respect to liability arising out of the Named Insured's work performed on behalf of the certificate holder and owner. This insurance will apply on a primary, non-contributory basis. A Blanket Waiver of Subrogation applies for General Liability, Automobile Liability and Umbrella/Excess Liability. Limited Contractual Liability is included. The Umbrella / Excess Liability policy provides excess coverage over the General Liability, Automobile Liability and Employers Liability. ACORD 101 (2008/01) © 2008 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD A�!Z�� CERTIFICATE OF LIABILITY INSURANCE Fil/2/2010'YYY' 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 Van Gilder Insurance Corp. 1515 Wynkoop, Suite 200 Denver CO 80202 CONTACT NAME: Dawn Gaba an PHONE FAX _[A/C,No, Ext: 9_3—$37_8.5_QQ _Iac.NI.34_3_$31_5295 EMAIL ADDRESS: dgabayan@vgic.COm PRODUCER CUSTOMER ID #: STOASC INSURER(S) AFFORDING COVERAGE NAIC # INSURED INSURER A: Hartford Insurance Company 0 Stolfus & Associates, Inc. 5690 DTC Boulevard INSURERB:XL Specialty Insurance Co. 0 INSURERC: Suite 101W - INSURER D: Greenwood Village CO 80111 INSURER E : INSURER F : COVERAGES CERTIFICATE NUMBER: 952928640 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, INSR LTR I TYPE OF INSURANCE IADOL� INSR SUBR I WVD POLICY NUMBER POLICY EFF MM/DD/YYYY POLICY EXP MMIDD LIMITS A GENERAL LIABILITY Y Y 34SBWPD4904 10/1/2010 10/1/2011 EACH OCCURRENCE $1,000,000 X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE 1 -- 1 OCCUR DAMAGE TO RENTED PREMISES (Ea ocairrence)__ $1, _()0 0-' 000 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 X PRO- LOC $ A AUTOMOBILE LIABILITY Y y 34SBWPD4904 10/1/2010 10/1/2011 COMBINED SINGLE LIMIT (Ea accident) $1, 000, 000 ANY AUTO BODILY INJURY (Per person) $ ALL OWNED AUTOS BODILY INJURY (Per accident) $ X SCHEDULED AUTOS HIRED AUTOS PROPERTY DAMAGE (Per accident) $ $ X NON -OWNED AUTOS $ A LIAB X OCCUR �Y Y 34SBWPD4904 10/1/2010 10/1/2011 EACH OCCURRENCE $1,000,000 NUMBRELLA AGGREG__A_TE $1, 000, 000 EXCESS LIAB CLAIMS -MADE HXDEDUCTIBLE $ $ RETENTION $10,000 WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y / N ANY PROPRIETOR/PARTNER/EXECUTIVE WC STATU- I JOTH- TORY LIMITS1 I ER E.L. EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? ❑ N / A E.L. DISEASE - EA EMPLOYE $ (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT $ B Professional Liability DPS9689446 10/1/2010 10/1/2011 Per Claim $1,000,000 Claims Made Annual Aggregate $1,000,000 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required) If required by written contract or written agreement, the following provisions apply subject to the policy terms, conditions, limitations and exclusions: The Certificate Holder and Owner are included as Additional Insureds for ongoing and completed operations under General Liability; Automobile Liability; See Attached... 17���117191\�7iC•J�9a�1 City of Fort Collins -Financial Purchasing Division 215 N Mason Street, 2nd F1; PO 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. Services BOX 580 AUTHORIZED REPRESENTATIVE •-��A-� ©1988-2009 ACORD CORPORATION. All rights reserved. ACORD 25 (2009/09) The ACORD name and logo are registered marks of ACORD AGENCY CUSTOMER ID: STOASC LOC #: .4�0!2o ADDITIONAL REMARKS SCHEDULE Page 1 of 1 AGENCY NAMED INSURED Van Gilder Insurance Corp. Stolfus & Associates, Inc. 5690 DTC Boulevard Suite 101W POLICY NUMBER Greenwood Village CO 80111 CARRIER NAIC CODE EFFECTIVE DATE: ADDITIONAL REMARKS THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, FORM NUMBER: 25 FORM TITLE:CERTIFICATE OF LIABILITY INSURANCE and Additional Insured under Umbrella / Excess Liability but only with respect to liability arising out of the Named Insured's work performed on behalf of the certificate holder and owner. This insurance will apply on a primary, non-contributory basis. A Blanket Waiver of Subrogation applies for General Liability, Automobile Liability and Umbrella/Excess Liability. Limited Contractual Liability is included. The Umbrella / Excess Liability policy provides excess coverage over the General Liability, Automobile Liability and Employers Liability. RE: City of Fort Collins Additional Insured: City of Fort Collins ACORD 101 (2008/01) ©2008 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD