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Home My WebLink About453145 INDEPENDENT ROOFING INC - INSURANCE CERTIFICATEP/NN/.1COL ASSURANCE INSURED: INDEPENDENT ROOFING INC 405 22ND STREET GREELEY CO 80631 ENDORSEMENT: Waiver Of Subrogation 7501 E Lowry Blvd Denver, CO 80230-7006 Phone: (303) 361-4000 / (800) 873-7242 Fax: (303) 361-5000 / (888) 329-2251 www.r)innacol.com NCCI #: WC000313 Policy #: 866470 We have the right to recover our payments from anyone liable for an injury covered by this policy. We will not enforce our right against the person or organization named in the Schedule. (This agreement applies only to the extent that you perform work under a written contract that requires you to obtain this agreement from us.) This agreement shall not operate directly or indirectly to benefit anyone not named in the Schedule. SCHEDULE City of Fort Collins P.O. Box 580 Fort Collins CO 80522 Effective Date: January 3, 2011 Expires on January 1, 2012 Pinnacol Assurance has issued this endorsement January 3, 2011. Charles Doggett Underwriter Pinnacol Assurance' 7501 E Lowry Blvd' Denver, CO 80230 Page 1 of 3 PINNAWEB- External / EMP Record Onl 01/03/2011 21:44:03 866470 Updated:02/01/2007 UW137 ACORDTM CERTIFICATE OF LIABILITY INSURANCE DATE (MM1 YY) 01/03/201l201 PRODUCER PINNACOL ASSURANCE THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY 7501 E Lowry Blvd AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS Denver, CO 80230-7006 CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. INSURERS AFFORDING COVERAGE NAIC# INSURED INDEPENDENT ROOFING INC INSURER A: PINNACOL ASSURANCE 41190 INSURERS: 405 22ND STREET INSURERC: GREELEY, CO 80631 INSURER D: INSURER E: COVERAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDNG ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMMENT 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 ADD'L POLICY EFFECTIVE POLICY EXPIRATION LTR INSRD TYPE OF INSURANCE POLICY NUMBER DATE(MM/DD/YYYY) DATE(MM/DD/YYYY) LIMITS GENERAL LIABILITY EACH OCCURRENCE DAMAGE TO RENTED COMMERCIAL GENERAL LIABILITY CLAIMS MADE OCCUR PREMISES MED EXP(.o.ny one person) PERSONAL B ADV INJURY GEN'L AGGREGATE LIMIT APPLIERS PER: GENERAL AGGREGATE PRODUCTS - COMP/OP AGG POLICY PROJECTD LOC AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT ANY AUTO (Ea Accident) BODILY INJURY ALL OWNED AUTOS SCHEDULEDAUTOS (Per person) BODILY INJURY HIRED AUTOS NON -OWNED AUTOS (Per accident) PROPERTY DAMAGE (Peraccident) GARAGE LIABILITY AUTO ONLY - EA ACCIDENT OTHER THAN EA ACC ANY AUTO AUTO ONLY: AG EXCESS/UMBRELLA LIABILITY OCCUR CLAIMS MADE EACH OCCURRENCE AGGREGATE DEDUCTIBLE RETENTION $ WORKERS COMPENSATION AND WC STATU- OTHER A EMPLOYER'S LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE 866470 01/01/201.1 01/01/2012 TORY LIMITS El EACH ACCIDENT $1,000,000 OFFICER/MEMBER EXCLUDED? E.L DISEASE - EA EMPLOYEE $1,000,000 If yes, please describe under SPECIAL PROVISIONS below El DISEASE- POLICY LIMIT $1,000,000 OTHER DESCRIPTION OF OPERATIONS/LOCATIONSNEHICLES/EXCLUSIONS ADDED BY ENDORSEMENTISPECIAL PROVISIONS CERTIFICATE HOLDER CANCELLATION 1281316 City of Fort Collins P.O. Box 580 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING COMPANY WILL ENDEAVOR TO MAIL 10 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE Fort Collins CO 80522 LEFT, BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE COMPANY, ITS AGENTS OR REPRESENTATIVES. AUTHORIZED REPRESENTATIVE ACORD 25 2001/08 Charles Doggett Underwriter ACORD CORPORATION 1988 �4CORDTM CERTIFICATE OF LIABILITY INSURANCE DATE (MM3/2011 YY) 01 /03/2011 PRODUCER PINNACOL ASSURANCE THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY 7501 E Lowry Blvd AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS Denver, CO 80230-7006 CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. INSURERS AFFORDING COVERAGE NAIC# INSURED INDEPENDENT ROOFING INC INSURERA: PINNACOL ASSURANCE 41190 INSURER B: 405 22ND STREET INSURER C: GREELEY, CO 80631 INSURER D: INSURER E COVERAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDNG ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMMENT 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 ADD'L POLICY EFFECTIVE POLICY EXPIRATION LTR INSRD TYPE OF INSURANCE POLICY NUMBER DATE(MM/DD/YYYY) DATE(MM/DD/YYYY) LIMITS GENERAL LIABILITY EACH OCCURRENCE COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED CLAIMS MADE OCCUR PREMISES MED EXP(Any one personZ_ PERSONAL & ADV INJURY GEN'L AGGREGATE LIMIT APPLIERS PER: GENERAL AGGREGATE PRODUCTS - COMP/OP AGG POLICY PROJECTE LOC AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT ANY AUTO (Ea Accident) BODILY INJURY ALL OWNED AUTOS SCHEDULED AUTOS (Per person) HIRED AUTOS BODILY INJURY NON -OWNED AUTOS (Per accident) PROPERTY DAMAGE t (Per accident) GARAGE LIABILITY AUTO ONLY - EA ACCIDENT OTHER THAN EA ACC ANY AUTO . AUTO ONLY: AG EXCESS/UMBRELLA LIABILITY EACH OCCURRENCE AGGREGATE OCCUR CLAIMS MADE DEDUCTIBLE RETENTION $ WORKERS COMPENSATION AND X WC STATU- OTHER A EMPLOYER'S LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE 866470 01/01/2011 01/01/2012 TORY LIMITS E.L EACH ACCIDENT $1,000,000 OFFICER/MEMBER EXCLUDED? E.L DISEASE - EA EMPLOYEE $1,000,000 If yes, pleasedescdbe under SPECIAL PROVISIONS below E.L DISEASE- POLICY LIMIT 1 000,000,000 OTHER DESCRIPTION OF OPERATIONS/LOCATIONSIVEHICLESIEXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS CERTIFICATE HOLDER CANCELLATION 1281206 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE City of Fort Collins THE EXPIRATION DATE THEREOF, THE ISSUING COMPANY WILL ENDEAVOR TO P.O. Box 580 MAIL 10 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE Fort Collins CO 80522-0580 LEFT, BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE COMPANY, ITS AGENTS OR REPRESENTATIVES. AUTHORIZED REPRESENTATIVE Charles Doggett ACORD 25(2001/08) Underwriter ACORD CORPORATION 1988 ACORDTM CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) 01 /03/2011 PRODUCER PINNACOL ASSURANCE THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY 7501 E Lowry Blvd AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS Denver, CO 80230-7006 CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. INSURERS AFFORDING COVERAGE NAIC# INSURED INDEPENDENT ROOFING INC INSURER A: PINNACOL ASSURANCE 41190 INSURER B: 405 22ND STREET INSURER C: GREELEY, CO 80631 INSURER D: INSURER E: COVERAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDNG ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMMENT 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 ADD'L I I POLICY EFFECTIVE POLICY EXPIRATION LTR INSRD TYPE OF INSURANCE POLICY NUMBER DATE(MM/DD/YYYY) DATE(MM/DD/YYYY) LIMITS GENERAL LIABILITY EACH OCCURRENCE DAMAGE TO RENTED COMMERCIAL GENERAL LIABILITY CLAIMS MADE 0 OCCUR PREMISES MED EXP(Any one person) PERSONAL& ADV INJURY GEN'L AGGREGATE LIMIT APPLIERS PER: GENERAL AGGREGATE PRODUCTS - COMP/OP AGG POLICY PROJECT LOC AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT ANY AUTO (Ea Accident) BODILY INJURY ALL OWNED AUTOS SCHEDULED AUTOS (Per person) BODILY INJURY HIRED AUTOS NON -OWNED AUTOS ( Per accident) PROPERTY DAMAGE (Per accident) GARAGE LIABILITY AUTO ONLY- EA ACCIDENT OTHER THAN EA ACC ANY AUTO AUTO ONLY: AG EXCESS/UMBRELLA LIABILITY EACH OCCURRENCE AGGREGATE OCCUR CLAIMS MADE DEDUCTIBLE RETENTION $ WORKERS COMPENSATION AND WC STATU- OTHER A EMPLOYER'S LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? 866470 01/01/2011 01 /01 /2012 TORY LIMITS E.1- EACH ACCIDENT $1,000,000 E.L DISEASE- EA EMPLOYEE $1,000,000 If yes, please describe under SPECIAL PROVISIONS below E.1- DISEASE- POLICY LIMIT $1,000,000 OTHER DESCRIPTION OF OPERATIONS/LOCATIONSA/EHICLES/EXCLUSIONS ADDED BY ENDORSEMENTISPECIAL PROVISIONS CERTIFICATE HOLDER CANCELLATION 1281294 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE City of Fort Collins THE EXPIRATION DATE THEREOF, THE ISSUING COMPANY WILL ENDEAVOR TO PO Box 580 MAIL 10 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE Fort Collins CO 80522-0580 LEFT, BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE COMPANY, ITS AGENTS OR REPRESENTATIVES. AUTHORIZED REPRESENTATIVE Charles Doggett ACORD 25(2001/08) Underwriter ACORD CORPORATION 1988