HomeMy WebLinkAboutCITY OF FORT COLLINS - INSURANCE CERTIFICATE (14)A� V CERTIFICATE OF LIABILITY INSURANCE
DATE o /2° 1'"
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 endorsements .
PRODUCER 1-303-773-9999
Arthur J. Gallagher Risk Management Services, Inc.
CONTACT NAME: Anita Bruner
PHONE 303-889-2574 FAX
-889-2575C No Est AIC No: 303
E-MAC snits b=er@ajg.com
ADDRESS:
6399 S. Fiddlers Green Cir
Suite 200
Greenwood Village, CO 80111
Karen Graham
INSURERS AFFORDING COVERAGE
NAICa
INSURERA: MIDWEST EMPLOYERS CAS CO
23612
INSURED
INSURERS:
City of Fort Collins
INSURER C
INSURER D:
P O Box 580
INSURER E: -
Fort Collins, CO 80522
INSURER F :
COVERAGES CERTIFICATE NUMBER: 21072825 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
INSR
WD
POLICY NUMBER
MMIDPOLIor EFF
MhUDD EXP
LIMIT
GENERAL LIABILITY
EACH OCCURRENCE
$
COMMERCIAL GENERAL LIABILITY
AMAGE TO RENTED
PREMISES Ea occurrence
$
CLAIMS -MADE OCCUR
MED EXP(Any one person)
S
PERSONAL B ADV INJURY
$
GENERAL AGGREGATE
$
GEN'L AGGREGATE LIMIT APPLIES PER:
PRODUCTS - COMP/OP AGG
S
$
POLICY F I PRb LOC
AUTOMOBILE LIABILITY
COMBINED SINGLE LIMIT
Eea ddeM
BODILY INJURY (Par Person)
S
ANY AUTO
BODILY INJURY (Per accident)
$
ALL OWNED SCHEDULED
AUTOS AUTOS
PROPERTYDAMAGE
Peraccident
E
NON -OWNED
HIRED AUTOS AUTOS
E
UMBRELLA LIAR
OCCUR
EACH OCCURRENCE
$
AGGREGATE
$
EXCESS LIMB
CLAIMS -MADE
DED I I RETENTIONS
$
A
WORKERS COMPENSATION
AND EMPLOYERS' LIABILITY
ANY PROPRIEfOMPARTNENEXECUTIVE YIN
EWC005901
05/01/1
05/01/12
X WCSTATU- OTH-
E.L. EACH ACCIDENT
$ 1, 000,000
OFFICEWMEMBER E%CLUOEOi
NIA
(Mandatory In NH)
E.L. DISEASE -EA EMPLOYE
$$ 1, 000, 000
E.L. DISEASE -POLICY LIMIT
$ 1, 000 , 000
If yes, describe under
DE SCRIPTION OF OPERATIONS below
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101, Additional Remarks Schedule, If mom space Is required)
Evidence of Insurance. For WC Policy - Self Insured Retention of $400,000 (CLASS CODE #7539 SIR of $750,000).
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
City of Fort Collins, CO THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
P O Box 580 AWHORRED REPRESENTATIVE / `/ p (�
Fort Collins, CO 80522 �/ `—\ 7 \'
1 USA /`Y.e.�.....
ACORD 25 (2010/05) The ACORD name and logo are registered marks of ACORD
anibru
21072825