HomeMy WebLinkAboutJANSMA BROS EXCAVATING & TRUCKING CORP - INSURANCE CERTIFICATE/� UP ID:
CERTIFICATE OF LIABILITY INSURANCE DAToa/o it)
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
PRODUCER 970-635-9400
PFS Insurance Group - JT 9
4848 Thompson Pkvvy, Ste 200
Johnstown, CO 80534
Tad Borrett
INSURED Jansma Bros. Excavating
& Trucking Corp.
1475 Backhoe Road
Loveland, CO 80538
INSURER A: Mountain States Insurance Grp
IM%HRFRR Pinnacol Assurance 41190
D:
COVERAGES CERTIFICATE NUMBER: 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.
LEXle
Tq TYPE OF INSURANCE ADOLI$UBRI POLICY NUMBER MM DDPOLICyYVYY MMIDDYYYYY LIMITS
A
GENERAL LIABILITY
X COMMERCIAL GENERAL LIABILITY
CLAIMS -MADE a OCCUR
X I Blanket Add'I Ins
CPP0117096
04111111
04/01/12
EACH OCCURRENCE
DAMAGE TO TRENTED
PREMISES (Ea occurrence)
$ 1,000,000
$ 10Q,00
MEDE%P(Anyoneperson)
Y 10,00
PERSONAL &ADV INJURY
$ 1,000,00
X Blanket Waiver
GENERAL AGGREGATE
$ 2,000,000
GEN'L AGGREGATE LIMIT APPLIES PER:
PRO
POLICY X 1 LOC
PRODUCTS-COMPIOP AGG
$ 2,000,000
$
A
A
A
AUTOMOBILE
LIABILITY
ANY AUTO
ALL OWNED AUTOS
SCHEDULED AUTOS
HIREDAUTOS
NON -OWNED AUTOS
BAP0117096
04/01/11
04/01/12
BINEDSINGLE LIMIT
C COMBINED
$ 1,000,00
X
BODILY INJURY (Per person)
$
BODILY INJURY (Per accident)
$
PROPERTY DAMAGE
(Per accitlent)
4 .
$
X
X
$
g
A
UMBRELLA AB LIAB
E%CESS LI
X
OCCUR
CLAIMS -MADE
UMB0117096
04/01/11
04/01/12
EACREGATEH OCCUR
$ 1,000,00
AGG
1,000,00RENCE
$
RETOENTIOE N$
$
B
wOaRER$cOMPENBATION _.
AND EMPLOYERS' LIABILITY
ANY PROPRIETORJPARTNERIEXECUTIVE YIN
OFFICERIMEMBER EXCLUDED?
yand
(Mi In I
IDESCRIPTION OF OPERATIONS below
NIA
2342390
BLANKET WAIVER OF SU
O6/01/10
05/01/11
X OSTAT I I
RY LIMITSJ�ER
E.L. EACH ACCIDENT �$
100,00
EL.DISEASE - EA EMPLOYEEI$
100,00
E.L. DISEASE -POLICY LIMIT 1
$ 500,00
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ANach ACORD 101, AddlUonal Remarks Schedule, If more space is required)
ALL OPERATIONS - ALL LOCATIONS.
FORT CO
City of Fort Collins
P.O. Box 680
Fort Collins, CO 80522
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WALL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
AUTHORIZED REPRESENTATIVE
01988-2009 ACORD CORPORATION. All rights reserved.
ACORD 25 (2009/09) The ACORD name and logo are registered marks of ACORD