HomeMy WebLinkAbout460607 CAMELOT CLEANERS - INSURANCE CERTIFICATE (4)ACORDv CERTIFICATE OF LIABILITY
INSURANCE
DATEDe/22/2011z/aou
PRODUCER (970) 377-0638
Squires insurance Solutions LLC
4025 Automation Way
Bldg B. Suite 4
Fort Collins CO 80525-
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
INSURERS AFFORDING COVERAGE
NAICN
INSURED
Dean Archambo, dba
Camelot Cleaners
2649 B Mulberry St, Ste 11A
Fort Collins CO 80524-
INSURERAHartford Casualty Ins Cc
INSURERB:Sentinel Insurance Cc
INSLRERCPinnacol Assurance
INBURFR D:
INSURERS
r-nvc R A. -cc
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 MAYBE ISSUED OR MAY PERTAIN,
THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.
AGGREGATE LIM ITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
II
LTR
ADUN
NSR
TYPE OF INSURANCE
POLICY NUMBER
POLICY EFFECTIVE
DATE(NMX)OMI)
f+DUCY FITPIRATION
DATE(MMMOM)
LIMITS
A
X
GENERALLMNUTY
34 SBA I99881
08/29/2011
08/29/2012
EACHOCCURRMCE
$ 110001000
PREMISES Ee ocwrnru
$ 300,000
X COMMERCIALGENERALUABILRY
CLAIMS MADE X OCCUR
/ /
/ /
MED E%P M one aeon
8 10,000
PERSONAL 3ADV INJURY
$ 1,000,000
GENERAL AGGREGATE
$ 2,000,000
GEN'LAGGREGATE LIMIT APPLIES PER:
PROOJCTS COMP/OPAGG
$ 2,000,000
POLICY 7 JECOT LOG
/ /
/ /
3?L2
51090
B
X
AUTOMOBILE
LIABILITY
ANYAUTO
34 DEC JJ784
08/29/2011
08/29/2012
COMBINEDSINGI£UMIT
(Ev=derl)
$ 11000,000
BODILY INJURY
Per Pawn)
IS
X
ALL OWNED AUTOS
SCHEDULED AUTOS
/ /
/ /
BODILY INJURY
(Perew.M1 nQ
$
X
X
HIREDAUTOS
NON OWNED ALTOS
/ /
/ /
PROPERTYDAMAGE
(Per eccidenQ
$
GARAGE UABILTTY
ALTO ONLY EAACOIDENT
$
OTHERTHAN EA ACC
$
ANYAUTO
I I
/ /
$
AUTO ONLY: AGG
A
X
EXCESSAJMBRELLA LIABILITY
34 SBA. Isseal
08/29/2011
06/29/2012
EACH OCCURRENCE
$
X OG R CLAIMS MADE
AGGREGATE
$
R168L
$ 2,000,000
X DEDUCTIBLE
$
RETENTION 3TH
C
WORKERS COMPENSATION AND
EMPLOYERS' LIABILITY
ANY PROPRETORPARTNEREXECLTNE
4142182
08/29/2011
09/01/2012
X TORY LIMBS ER
E.L EACH ACCIDENT
IS 100,000
E.LDISEASE EAEMPLOYE
$ 100,000
OFFICERME10MREXCLLDED7
/ /
/ /
If ym, tleecnbe under
SPECIALPROVISIONSbelow
E.LDISEASE POUCYLIMR IS
500,000
A
OTHER BOPPR
34 SBA I59881
08/29/2011
08/29/2012
DESCRIPTIONOFOPEPATIONSILOCATIONSMEHICLEBI CLU&MSAODEDSYENDORSEMEWISPECIALPRONSIONS
COatraCt 1f7037 - Dry Cleaning Gervicee.
Certificate Rolder ie listed an Additional Iaecred . the policy ae per policy forme sag coodi liana.
CERTIFICATE HOLDER CANCELLATION
(970) 221-6775 (970) 221-6707
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE
Purchasing Department
EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL
10 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT. BUT
City Of Fort Collins
FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE
PO BOX 580
INSURER, ITS AGENTS OR REPRESENTATIVES,
AUTHORIZED REPRESENTATIVE —
Fort Collins CO 80527-
ACORD 25 (2001/08)
INS025 (0108).0e
1) ACORD CORPORATION 1988
P., 1of2
IMPORTANT
If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. A statement an this
certificate does not confer rights to the certificate holder in lieu of such endorsement(s).
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).
DISCLAIMER
The Certificate of Insurance on the reverse side of this form does not constitute a contract between the issuing
insurer(s), authorized representative or producer, and the certificate holder, nor does it affirmatively or negatively
amend, extend or after the coverage afforded by the policies listed thereon.
ACORD 25 (2001008)
INS025(oloe).a6 AMS P,.2 d2