HomeMy WebLinkAbout460000 AMERICAN PALLET AND TRUCK WASH - INSURANCE CERTIFICATEOr
STATE FARM INSURANCE COMPANIES'
1555 Promontorryy Circle
Greeley CO 80636-0001
DATE OF NOTICE: SEP 14 2010
CODE:
125
AT 1 20 A
002007
CITY'S DIRECTION OF
PURCHASINGAND RISK MANAGEMENT
PO BOX 580
FORT COLLINS CO 80522-0580
NOTE: PLEASE NOTIFY STATE FARM AT THE
ADDRESS LISTED AT THE TOP, LEFT CORNER
OF THIS PAGE REGARDING ANY CHANGE OF
ADDRESS INFORMATION.
State Farm Mutual Automobile Insurance Company 1933-F911-V
NAMED INSURED: POLICY NO: 671264-F23-06G COVERAGE:
AMERICAN PALLET & TRUCK WASH YR/MAKE/MODEL: 1994 MITSUBISHI FLAT BED
N LLC VIN/CAMPER: JW60EGIGXRL003468
5975 S KENTON ST AGENT NAME: VOYVODIC INS AGENCY INC
m ENGLEWOOD CO 80111-5721 AGENT PHONE: (303)693-1600
3RD PARTY INTEREST TERMINATED
m
EFFECTIVE SEP 27 2010
N POLICY MESSAGES:
Protection of the additional insured's interest provided by this policy is terminated as of the effective date above for the following reason:
Policy cancelled by insured. This advance notice is solely to protect the additional insured's interests as they are affected by the ownership,
maintenance, or use of the car described in the policy.
e
M
r
FAT
PINNACOL
ASSURANCE
CITY OF FORT COLLINS ATTN: JOHN STEPHENS
215 NORTH MASON STREET
FORT COLLINS CO 80521
INSURED:
AMERICAN PALLET AND TRUCK WASH LLC
3700 CANAL DR
FORT COLLINS CO 80524
7501 E Lowry Blvd
Denver, CO 80230-7006
Phone: (303) 361-4000 / (800) 873-7242
Fax: (303) 361-5000 / (888) 329-2251
www.pinnacol.com
November 23, 2010
Policy #: 4114186
Notice To Certificate Holder Of Cancellation
Pinnacol Assurance would like to inform you that the workers' compensation insurance policy through our
company for:
Policy #: 4114186
Insured: AMERICAN PALLET AND TRUCK WASH LLC
for whom you currently hold a certificate of workers' compensation insurance, has canceled as of November 9,
2010.
As always, Pinnacol Assurance continues to be Colorado's premier workers' compensation insurance company.
If you have any questions regarding this letter, or if I can be of further help, please contact me at the numbers
listed below.
Sincerely,
Cora Burris, Underwriter
Phone: (303) 361-4155 / (800) 873-7242
Fax: (303) 361-5150 / (888) 329-2215
Pinnacol Assurance' 7501 E Lowry Blvd' Denver, CO 80230
Page 1 of 1 ISA - External / EMP Record Onl 11/23/2010 18:44:49 4114186 Updated: 05/13/2008 P722