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Home My WebLink AboutROBERTS EXCAVATION CORPORATION - INSURANCE CERTIFICATE (6).� OKesCERTIFICATE OF LIABILITY INSURANCE OP ID DA DATE(MM/DOIYYYY) 06 10 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 certificate holder in lieu of such endorsement(s). PRODUCER NAMEPHONE FAX Eztl: (A/C, Ni Brown & Blown Inc 4532 Boardwalk Dr, Suite 200 EtAIC,IL7 ADDRESS: Fort Collins CO 80525 -PRODCER CUSTOMER ID #: ROHER-7 Phone:970-482-7747 Fax:970-484-4165 INSURER(S) AFFORDING COVERAGE NAIL# INSURED INSURER A: Mountain States Mutual 14648 Roberts Excavation Corporation Attn: Gerald Roberts INSURER B: Pinnacol Assurance Company 41190 INSURER C: 1801 let Street Berthoud CO 80513 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 BY PAID CLAIMS. LTR TYPE OF INSURANCE ISRUER II SWVDI POLICY NUMBER (MMIDD/YYYY) (MMIDDIYYYY) LIMITS A GENERAL LIABILITY X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE [ X] OCCUR CPP011475707 BLKT ADD'L INSD BLXT NAIYaII Or Srinab 04/01/11 04/01/12 EACH OCCURRENCE $ 1,000,000 PREMISES(Eaoccurrence) $100,000 MED EXP (Any one person) $ 10,000 PERSONAL B ADV INJURY $1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: POLICYFn l JECOT n LOC PRODUCTS - COMPIOP AGG $2,000,000 $ A AUTOMOBILE LIABILITY ANY AUTO ALL OWNED AUTOS SCHEDULED AUTOS HIREDAUTOS NON -OWNED AUTOS BAP011475707 BLKT ADDrL INSD 04/01/11 04/01/12 COMBINED SINGLE LIMIT (Ea accident) S1,000,000 X BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ PROPERTY DAMAGE (Per accident) $ $ $ A X UMBRELLA LIAR EXCESS LIAB X OCCUR CLAIMS -WOE UMB011475707 _ 04/01/11 04/01/12 EACH OCCURRENCE $ 1,000,000 AGGREGATE $1,000,000 DEDUCTIBLE RETENTION $ O $ X $ H WORKERS COMPENSATION AND EMPLOYERS' LIABILITY YIN ANY PROPRIETORIPARTNEWEXECUTIV5��y� OFFICERIMEMBER EXCLUDED? — (Mandatory In NH) If yes, describe under DESCRIPTION OF OPERATIONS below NIA _ 3241433 o6/oi/11 06/01/12 X A U- - TORV LIMITS ER E.L. EACH ACCIDENT $lOOOOOO E. L. DISEASE - EA EMPLOYEE $ 1000000 E.L. DISEASE -POLICY LIMIT I $ 1000000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required) Fax# 221-6707 CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE CITYFI O I THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. City of Fort Collins 215 N. Mason St. I __� ACORD 25 (2009109) The ACORD name and logo are registered marks of ACORD