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HomeMy WebLinkAboutJANSMA BROS EXCAVATING & TRUCKING CORP. - INSURANCE CERTIFICATEUr' IL): Di CERTIFICATE OF LIABILITY INSURANCE DATos/ 0/11 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 IFS Insurance Group -JT 970-635-9401 $848 Thompson Pkwy, Ste 200 Johnstown. CO 80534 INSURED Jansma Bros. Excavating & Trucking Corp. 1475 Backhoe Road Loveland, CO 80538 COVERAGES CERTIFICATE NUMBER: JANSM-3 INSURER A: Mountain States Insurance Grp INSURER B- Pinnacol Assurance 141190 INSURER D : 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 TYPE OF INSURANCE AORI WAD POLICY NUMBER MMIDDIYYYY MM LTR IDDIVYYY LIMITS A GENERAL LIABILITY X COMMERCIAL GENERAL LIABILITY CLAIMSWADE OCCUR X BlanketAdd'llns CPP0117096 04/01/11 04/01/12 EACH OCCURRENCE DAMAGE TO RENTED PREMISES_(E_a_occurrence] MED EXP(Any one person) $ 1,000,00 $ 100,00 $ 10,000 PERSONAL BADVINJURY $ 1,000,000 X Blanket Waiver GENERALACGREGATE $ 2,000,000 GEH'L AGGREGATE LIMIT APPLIES PER. POLICY A PRO n LOC PRODUCTS-COMPIOPAGG $ 2,000,000 $ A A A LIABILITY ANY AUTO ALL OWNED AUTOS SCHEDULEDAUTOS HIRED AUTOS NON-OWNEDAUTOS BAP0117096 04/01/11 04/81/12 COMBINED SINGLE LIMIT (Ea accident) $ 1,000,000 MOMOBILE BODILY INJURY (Per person) $ X X BODILYINJURVIPer accident) $ PROPERTY (Peia ctleno DAMAGE $ $ A UMBRELLA LIAR LI OCCUR EXCESS LIAB CLAIMS -MADE UMB0117096 04/01/11 04/01/12 EACH OCCURRENCE $ 1,000,000 AGGREGATE $ 1,000,00 DEDucneLE RETENTION $ $ $ B WORKERS COMPENSATION AND EMPLOYERS'LIABILITY ANY PROPRIETOR/PARTNERIEXECUTIVE YIN OFFICERIMEMEER EXCLUDED? (Mandatory In NH) es describe under DESCRIPTION OF OPERATIONS below -- NIA - - - -- - -- 2342390 BLANKET WAIVER OF SU 06/01/11 _ _ 06/01/12 X TQRVLIMITS�ER E.L. EACH ACCIDENT $ 100,00 DISEASE - EA EMPLOYEE$ 100,000 ELIf E.L. DISEASE -POLICY LIMIT $ 500,00 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101, Additional Remarks Schedule, If more space Is required) ALL OPERATIONS - ALL LOCATIONS. 1&1.4111 City of Fort Collins P.O. Box 580 Fort Collins, CO 80522 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE 4aA-1-Z ©1988-2009 ACORD CORPORATION. All rights reserved. ACORD 25 (2009/09) The ACORD name and logo are registered marks of ACORD UP IU: KU '`'� o..... CERTIFICATE OF LIABILITY INSURANCE DAT05110111 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 WANED, 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 970-635-9400 PFS Insurance Group - JT 4848 Thompson Pkwy, Ste 200 970-635-9401 Johnstown, CO 80534 Tad Borrett CONTACT PHONE FAX AI IC. No Eirtl: (AC, No): EMAIL ADDRESS: PRODUCER 10 a: JANSM-3 _CUSTOMER _ INSURER(S) AFFORDING COVERAGE NACp INSURED Jansma Bros. Excavating INSURER A: Mountain States Insurance Grp & Trucking Corp. INSURER B: Pinnacol Assurance 141190 1475 Backhoe Road Loveland, CO 80538 INSURER C INSURER D: INSURER E INSURER F 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 BYYPPAID CLAIMS. INSR ADDLTSUBR POLICY MMIODIYYYY MMIDDIYYYY LIMITS LTR TYPE OFINSURANCE POLICY NUMBER A GENERAL LIABILITY X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE 1K OCCUR X I Blanket Add'I Ins CPP0117096 04/01/11 04101/12 EACH OCCURRENCE DAMAGE TO RENTED PREMISES-fEeoccurrence) MED EXP (Any one Person) $ 1,000,000 1 100,00 1 $ $ 10,00 PERSONAL S ADV INJURY $ 1,000,00 X Blanket Waiver GENERAL AGGREGATE $ 2,000,00 GENL AGGREGATE LIMIT APPLIES PER: POLICY X PRO- F LOC IrCT PRODUCTS - COMPMP AGG $ 2,000,00 $ A A A AUTOMOBILE LIABILITY ANY AUTO ALL OWNED AUTOS SCHEDULED AUTOS HIREDAUTOS NON-OWNEDAUTOS BAP0117096 04/01/11 04101/12 COMBINED SINGLE LIMIT (Ea accident) $ 1,000,000 X BODILY INJURY (Per person) $ BOOILYINJURY (Per accitlent) $ PROPERTYDAMAGE (Per accitlent) $ X X $ $ A UMBRELLA LIAB Al OCCUR EXCESS LIAB CLAIMS -MADE I I UMB0117096 04101/11 04/01/12 EACH OCCURRENCE $ 1,000,00 AGGREGATE $ 1,000,00 DEDUCTIBLE RETENTION $ $ $ B WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANY PROPRIETOR/PARTNERIEXECUTIVE YO OFFICERIMEMBER E%CLUDEDP (Mandatory In NH) If yes describe un, DESCRIPTION OF OPERATIONS below NIA 2342390 BLANKET WAIVER OF SU 06/01/11 06/01/12 WCSTATU- GR- X TORV LIMITS ER E.L. EACH ACCIDENT $ 100,00 EL.DISEASE -EA EMPLOYEE$ 100,00 E. L. DISEASE -POLICY LIMIT 1 $ 500,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101, Additional Remarks Schedule, it more space is required) ALL OPERATIONS - ALL LOCATIONS. CERTIFICATE HOLDER CANCELLATION FORT CO SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE -EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN City of Fort Collins ACCORDANCE WITH THE POLICY PROVISIONS. P.O. Box 580 AUT/HOORVEED REPRESENTATIVE Fort Collins, CO 80522 ACORD 25 (2009/09) © 1988-2009 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD