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HomeMy WebLinkAbout304997 BELFOR ENVIRONMENTAL INC - INSURANCE CERTIFICATE (2)A �® CERTIFICATE OF LIABILITY INSURANCE DAT PIM20 I1) 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 Aon Risk Services Central, Inc. Southfield MI office CONTACT NAME NC �ry .EXq: (866) 283-7122 FAX (847) 953-5390 E-0OOL ADDRESS: 3000 Town Center suite 3000 Southfield MI 48075 USA INSURER(S) AFFORDING COVERAGE NAIL R INSURED -1 O,1 Cl 'I Belfor Environmental, Inc. //� l� I I 5075 Kalamath Street Denver CO 80221 USA INSURER A: Pinnacol Assurance Company 41190 INSURER B: Insurance Company of the State Of PA 19429 INSURER C: National Union Fire ins Co of Pittsburgh 19445 INSURERD: Chartis Specialty Insurance Company 26883 INSURER E: INSURER F: [@fail4:L[H*�N4:ruy[9_\t:1:[gJ,IA4;11b(II.LfI:I:r4YI t :I=III&4U7:[: n17,1_14: 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. Limits shown are as requested LTR TYPE OF INSURANCE INSR YryD POLICY NUMBER MMIDD MMIDD LIMBS C GENERAL I -MR -MY GL EACH OCCURRENCE S1,000,000 X COMMERCIAL GENERAL LIABILITY SIR applies per policy terns & Condi ions N PREMISES Ea occurrence 51, 000, 000 CLAIMS -MADE ❑% OCCUR MED EXP(Anyone person) S100,000 PERSONAL& ADV INJURY $1,000,000 GENERAL AGGREGATE S2,000, 000 GENL AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMPIOP AGO S2,000, 000 POLICY X PRo- X JSCT LOC B AUTOMOBILE LIABILITY CA 8 6-38-25 04/01/2011 04/01/2012 COMBINED SINGLE LIMIT Ea accident $1,000,000 BODILY INJURY (Par Person) X ANYAUTO X ALL OWNED SCHEDULED AUTOS AUTOS % HIRED AUTOSNXNONOWNEDPROPERTY AUTOS BODILY INJURY (Per accident) DAMAGE Peraccidenl X con D. Etp00 CamP Due $1," B % UMBRELI-4LIAR X OCCUR 9788925 04/01/2011 04/01/2012 EACH OCCURRENCE $5,000,000 EXCESS LIAI CLAIMS -MADE SIR applies per policy terns & condi ions AGGREGATE $5,000,000 DEO I % RETENTION 510, 000 C A WORKERS COMPENSATION AND EMPLOYERS' LIABILITY YIN ANY PROPRIETOR I PARTNER I EXECUTIVE OFFICERIMEMBER EXcwDEDi FN9 NIA WCO20635377 ADS 4051232 04/01 2011 12/01/2010 04/01/2012 12/01/2011 X WC STATU- OTH- TORY LIMITS ER E.L EACH ACCIDENT $1,000,000 EL DISEASE -EA EMPLOYEE $1.000,000 (Mandatory in NM CO Ity descnbe under DESCRIPTION OF OPERATIONS below E.L. DISEASE -POLICY LIMIT $1,000,000 D Contractor Poll CP016851546 04/01/2011 04/01/2012 Agg/OCC S15, 000,000 Deductible $100,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Anach ACORD 101, Additional Remarks Schedule, It more space is required) Re: Fort Collins ER Contract The City of Fort Collins is included as Additional insured with respects to General Liability. waiver of Subrogation applies as required by contract. CERTIFICATE HOLDER CANCELLATION 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 AUTHORIZED REPRESENTATIVE Attn. James O'Neil II, CPPO,CPPB 2nd For North ns CO, 052 Floori -- P.O. Box 580 //✓�1LN/!}Q-/G� Fort Collins CO 80522 USA k� flGt ©1988.2010 ACORD CORPORATION. All rights reserved. ACORD 25 (2010/05) The ACORD name and logo are registered marks of ACORD A �® CERTIFICATE OF LIABILITY INSURANCE DAT PIM20 I1) 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 Aon Risk Services Central, Inc. Southfield MI office CONTACT NAME NC �ry .EXq: (866) 283-7122 FAX (847) 953-5390 E-0OOL ADDRESS: 3000 Town Center suite 3000 Southfield MI 48075 USA INSURER(S) AFFORDING COVERAGE NAIL R INSURED -1 O,1 Cl 'I Belfor Environmental, Inc. //� l� I I 5075 Kalamath Street Denver CO 80221 USA INSURER A: Pinnacol Assurance Company 41190 INSURER B: Insurance Company of the State Of PA 19429 INSURER C: National Union Fire ins Co of Pittsburgh 19445 INSURERD: Chartis Specialty Insurance Company 26883 INSURER E: INSURER F: [@fail4:L[H*�N4:ruy[9_\t:1:[gJ,IA4;11b(II.LfI:I:r4YI t :I=III&4U7:[: n17,1_14: 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. Limits shown are as requested LTR TYPE OF INSURANCE INSR YryD POLICY NUMBER MMIDD MMIDD LIMBS C GENERAL I -MR -MY GL EACH OCCURRENCE S1,000,000 X COMMERCIAL GENERAL LIABILITY SIR applies per policy terns & Condi ions N PREMISES Ea occurrence 51, 000, 000 CLAIMS -MADE ❑% OCCUR MED EXP(Anyone person) S100,000 PERSONAL& ADV INJURY $1,000,000 GENERAL AGGREGATE S2,000, 000 GENL AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMPIOP AGO S2,000, 000 POLICY X PRo- X JSCT LOC B AUTOMOBILE LIABILITY CA 8 6-38-25 04/01/2011 04/01/2012 COMBINED SINGLE LIMIT Ea accident $1,000,000 BODILY INJURY (Par Person) X ANYAUTO X ALL OWNED SCHEDULED AUTOS AUTOS % HIRED AUTOSNXNONOWNEDPROPERTY AUTOS BODILY INJURY (Per accident) DAMAGE Peraccidenl X con D. Etp00 CamP Due $1," B % UMBRELI-4LIAR X OCCUR 9788925 04/01/2011 04/01/2012 EACH OCCURRENCE $5,000,000 EXCESS LIAI CLAIMS -MADE SIR applies per policy terns & condi ions AGGREGATE $5,000,000 DEO I % RETENTION 510, 000 C A WORKERS COMPENSATION AND EMPLOYERS' LIABILITY YIN ANY PROPRIETOR I PARTNER I EXECUTIVE OFFICERIMEMBER EXcwDEDi FN9 NIA WCO20635377 ADS 4051232 04/01 2011 12/01/2010 04/01/2012 12/01/2011 X WC STATU- OTH- TORY LIMITS ER E.L EACH ACCIDENT $1,000,000 EL DISEASE -EA EMPLOYEE $1.000,000 (Mandatory in NM CO Ity descnbe under DESCRIPTION OF OPERATIONS below E.L. DISEASE -POLICY LIMIT $1,000,000 D Contractor Poll CP016851546 04/01/2011 04/01/2012 Agg/OCC S15, 000,000 Deductible $100,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Anach ACORD 101, Additional Remarks Schedule, It more space is required) Re: Fort Collins ER Contract The City of Fort Collins is included as Additional insured with respects to General Liability. waiver of Subrogation applies as required by contract. CERTIFICATE HOLDER CANCELLATION 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 AUTHORIZED REPRESENTATIVE Attn. James O'Neil II, CPPO,CPPB 2nd For North ns CO, 052 Floori -- P.O. Box 580 //✓�1LN/!}Q-/G� Fort Collins CO 80522 USA k� flGt ©1988.2010 ACORD CORPORATION. All rights reserved. ACORD 25 (2010/05) The ACORD name and logo are registered marks of ACORD