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HomeMy WebLinkAbout330179 INTERWEST CONSULTING GROUP - INSURANCE CERTIFICATE (11)AC"JZH CERTIFICATE OF LIABILITY INSURANCE DATE (MMI00/YYYY) 11 10 2011 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 jHOLDER. 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 CONTACT NAME: Kathy Van Gilder Insurance Corp. 1515 Wynkoop, Suite 200 Denver CO 80202 PHONE FAX -837-INC.No:3 - - 5295 IL EJAAN ADDRESS:kstar@vgic com, INSURERS) AFFORDING COVERAGE NAIC N INSURERA:XL pecialty InsurancQ INSURED INTCON6 I INSURER B:Tra Velers PrQp�rty Casual Co25674 INSURER C:PL-Travelers Indemnity Co of C 25682 Interwest Consulting Group INSURERD:The Phoenix Insurance Company 25623 1076 Lincoln Place Boulder CO 80302 INSURER E INSURER F : COVERAGES CERTIFICATE NUMBER: 558361600 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 rypE OF INSURANCE ADDL INSR SUBR MD POLICY NUMBER I POLICY EFF MM/DO/YYYY POLICY E%P MMIDD/YYYY LIMITS B GENERAL LIABILITY Y y 6807444M622 11/14/2011 1/14/2012 EACH OCCURRENCE $2, 000, 000 X COMMERCIAL GENERAL LIABILITY DAMAGEcoED PREMISESS(Ea Eaoccurrence 81, 000, 000 CLAIMS -MADE 171 OCCUR MED EXP(Any one person) $10, 000 PERSONALS ADV INJURY $2,000,000 GENERAL AGGREGATE $4,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMPIOP AGG $4, 000, 000 I POLICY ^ PRO 1 LOC $ C AUTOMOBILE LIABILITY y y BA7466M4291 11/14/2011 1/14/2012 Com Ea accident 1, 000, 000 BODILY INJURY (Per person) $ X ANY AUTO ALL OWNED SCHEDULED AUTOS AUTOS BODILY INJURY (Per strident)I$ X NON -OWNED HIRED AUTOS X AUTOS PROPERTY DAMAGE Per accident $ $ D X UMBRELLA LIAB OCCUR y y CUP1330T362 11/14/2011 1/14/2012 EACH OCCURRENCE $1, O0,:D0o AGGREGATE $1, 000, 000 EXCESS LIAB CLAIMS -MADE DIED I X I RETENTION$ 10, 000 $ B D WORKERS COMPENSATION AND EMPLOYERS' LIABILITY YIN ANY PROPRIETORIPARTNERIEXECUTIVE OFFICERIMEMBER EXCLUDED? � NIA y VMPJUB1339T93410 B1341TO51 11/14/2011 1/14/2011 1/14/2012 �1/14/2012 % WC STATU- OT1- in FIR 11 EACH ACCIDENT $1, 000, 000 E.L. DISEASE - EA EMPLOYEE $1, 000, 000 (Mandatory in NH) f yes, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE -POLICY LIMIT 1 $1, 000, 000 A Professional Liability PR9695279 11/14/2011 II11/14/2012 Per Claim $1,000,000 Claims Made Annual Aggregate $3,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101, Additional Remarks Schedule, If more space is required) If required by written contract or written agreement, the following provisions apply subject to the policy terms, conditions, limitations and exclusions: The Certificate Holder and Owner are included as Additional Insureds for ongoing and completed operations under General Liability, Automobile Liability, Umbrella / Excess Liability but only with respect to liability arising out of the Named Insured's work performed on behalf of the certificate holder and owner. This insurance will apply on a primary, non-contributory basis. A Blanket Waiver of Subrogation applies for General Liability, Automobile See Attached... L�_vma��evnJcl SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN City of Fort Collins, Purchasing ACCORDANCE WITH THE POLICY PROVISIONS. P.O. Box 580 Fort Collins CO 80522 AUTHORIZED REPRESENTATIVEE I —+T A -A @ 1988-2010 ACORD CORPORATION. All rights reserved ACORD 25 (2010105) The ACORD name and logo are registered marks of ACORD AC" j AGENCY CUSTOMER ID: INTCON6 LOC #: ADDITIONAL] REMARKS SCHEDULE Page I of I AGENCY Van Gilder Insurance Corp. NAMED INSURED Interwest Consulting Group 1076 Lincoln Place Boulder CO 80302 POLICY NUMBER i I CARRIER NAIL CODE EFFECTIVE GATE: ADDITIONAL REMARKS THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, FORM NUMBER: 25 FORM TITLE: CERTIFICATE OF LIABILITY INSURANCE Liability, Umbrella/Excess Liability and Workers' Compensation. Limited Contractual Liability is included. The Umbrella / Excess Liability policy provides excess coverage over the General Liability, Automobile Liability and Employers Liability. RE: College Avenue and Harmony Road Intersection Additional Insured: City of Fort Collins, its officers, agents and employees ACORD 101 (2008/01) © 2008 ACORD CORPORATION. All rights reserved The ACORD name and logo are registered marks of ACORD ACORH CERTIFICATE OF LIABILITY INSURANCE DATE (MMIDDNYYY) 11 10 2011 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 CONTACT NAME: ](atj]y_CYa Van Gilder Insurance Corp. PHONE FA% AIC 7 ac No :3 - - 1515 Wynkoop, Suite 200 -No E-MAIL Denver CO 80202 ADDRESS:kstar v ig _C- m INSURER(S) AFFORDING COVERAGE NAIC9 INSURERA:XL Speciajr.V lnaUranCe7 INSURED INTCON6 INSURER B:TraVe1_ers_PrQpj rty Casualt]_CO 5674_ 25682 Interwest Consulting Group INSURER C:PL-_Travgls_rs mnit Cc of C INSURER D:The Ph n_x Insurance Companv 25623 1076 Lincoln Place Boulder CO 80302 INSURER E INSURER F: COVERAGES CERTIFICATE NUMBER: 591537024 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 OFINSURANCE ADDL INSR BUBO VIVO POLICY NUMBER MM DDY"EFF POLICYEXP LIMITS B GENERAL LIABILITY Y Y 6807444M622 I11/14/2011 1/14/2012 EACHOCCURRENCE $2, 000, 000 X COMMERCIAL GENERAL LIABILITY I _EACH_ DAMGE TO RENTED PREMISES Ea occwrence $1, 000, 000 CLAIMS -MADE OCCUR MED EXP(Any one person) $10, 000 PERSONAL B ADV INJURY $2,000,000 GENERAL AGGREGATE $4,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: POLICY I^ PRO LOC PRODUCTS-COMPIOP AGG $4,000,000 i $ C OMOBILE LIABILITY Y Y BA7466M429 '11/14/2011 1/14/2012Eaaccitlenl 1,000,000 BODILY INJURY (Per person) $ ANY AUTO ALL OWNED SCHEDAUTOSULED P BODILY INJURY (Per accident)$AUTOSNON-OWNED PROPERTY DAMAGEHIRED ccident Per accident) $ AUTOS X AUTOS Is H X UMBRELLA LIAR OCCUR Y Y CUP1330T362' 11/14/2011 1/14/2012 EACH OCCURRENCE $1, 000, 000 AGGREGATE $1, 000, 000 EXCESS LIAB I I CLAIMS -MADE DED X RETENTION$10, 000 I $ H D WORKERS COMPENSATION AND EMPLOYERS' LIABILITY YIN ANY PROPRIETORIPARTNERIEXECUTIVE OFFICERIMEMBER EXCLUDED? NIA Y VMPJUB1339T93410 TB1341TO51 11/14/2011 11/14/2011 1/14/2012 1/14/2012 % WCSTATU- OTH- T RY IMIT ER E.L. EACH ACCIDENT $1, 000, 000 E.L. DISEABE-EA MPLOYER 1, 000, 000 (Mandatory in NH) If yes, describe under E.L. DISEASE- POLICY LIMIT $1, 000, 000 DESCRIPTION OF OPERATIONS below A Professional Liability Claims Made I 6PR9695279 11/14/2011 �1/14/2012 Per Claim $1,000,000 Annual Aggregate $3,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space Is required) If required by written contract or written agreement, the following provisions apply subject to the policy terms, conditions, limitations and exclusions: The Certificate Holder and Owner are included as Additional Insureds for ongoing and completed operations under General Liability, Automobile Liability, Umbrella / Excess Liability but only with respect to liability arising out of the Named Insured's work performed on behalf of the certificate holder and owner. This insurance will apply on a primary, non-contributory basis. A Blanket Waiver of Subrogation applies for General Liability, Automobile See Attached... City of Fort Collins, Purchasing 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 © 1988-2010 ACORD CORPORATION_ All rinhfc ACORD 25 (2010105) The ACORD name and logo are registered marks of ACORD A O � AGENCY CUSTOMER ID: INTCON6 LOC #: ADDITIONALI REMARKS SCHEDULE Page 1 of 1 AGENCY NAMED INSURED Van Gilder Insurance Corp. Tnterwest Consulting Group 1076 Lincoln Place Boulder CO 80302 POLICY NUMBER CARRIER NAIC CODE EFFECTIVE DATE: THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, FORM NUMBER: 25 FORM TITLE: CERTIFICATE OF LIABILITY INSURANCE ability, Umbrella/Excess Liability and Workers' Compensation. Limited Contractual Liability is eluded. The Umbrella / Excess Liability policy provides excess coverage over the General Liability, tomobile Liability and Employers Liability. : West Harmony Road Improvements Project ditional Insured: City of Fort Collins, its officers, agents and employees .+ wmu IV I I,UUoiU y V ZUUtl AGUKU GUKPURATION. All rights reserved. The ACORD name and logo are registered marks of ACORD ACORO® CERTIFICATE OF LIABILITY INSURANCE DATE ImM/DDlvvrr) 11 to zoll 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 NOTE' 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 CONTACT NAME: Kathy -Star Van Gilder IRSllraRCe Corp. 1515 Wynkoop, Suite 200 Deriver CO 80202 FA PNONE % - - AIC No : - - 2 E-MAIL ADDRESS: k S_tdr2V,gi_.s QUI INSURERS) AFFORDING COVERAGE NAIL If INSURER A:XL peCialty Insurance Co.885 INSURED INTCON6 INSURER 8:TTaV�1gr5s PTQAerty-Caspaltv_Oo 5674 INSURER c:pL=Tr v 1 In mni Co of C 5682 Interwest Consulting Group INSURERD:TY1 r`Ph nix Insurance Company ��23 1076 Lincoln Place Boulder CO 60302 INSURER E INSURER F : COVERAGES CERTIFICATE NUMBER: 480557824 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 I TYPE OF ADDLSUBR INSR WVD POLICY NUMBER I POLICY EFF MM/0 DJYYYY1 POLICY EXP MMUDDrYYYYJ LIMITS e GENERAL LIABILITY Y Y 6807444M622 11/14/2011 1/14/2012 EACH OCCURRENCE $2,000,000 % COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED PREMISES Ea ouunence $1, 000, 000 CLAIMS -MADE ❑ OCCUR MED EXP(Any one person) $10,000 PERSONAL B ADV INJURY $2,000,000 GENERAL AGGREGATE $4,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP/OP AGG $4,000,000 ECT POLICY ^ PRO n LOC $ C AUTOMOBILE LIABILITY Y Y BA7466M429 1/14/2011 1/14/2012 Ea aaitlent 1, 000, 000 X BODILY I NJ U RY(Per person) $ ANY AUTO ALL OWNED SCHEDULED AUTOS BODILY INJURY (Per accitlent) $ X NON-OAUTOS HIREDAUTOS H AUTOSWNED Perr amideREO,tKntDAMAGE $ B X UMBRELLA LAB OCCUR Y Y CUP133DT362 1/14/2011 III,'1/14/2012 EACH OCCURRENCE $1,000,000 AGGREGATE "0, 000 EXCESS LIAR CLAIMS -MADE DIED IX I RETENTION$ 10, DOD $1, B D WORKERS COMPENSATION AND EMPLOYERS' LIABILITY yIN ANY PROPRIETORIPARTNER/EXECUTIVE OFFICERIMEMBER EXCLUDED? N NIA y VMPJI1B1339T93410 1341TO51 11/14/2011 11/14/2011 1/14/2012 1/14/2012 X WC STATU- OTH- L. E.L. EACH ACCIDENT $1,000, 000 E.L. DISEASE - EA EMPLOYE $1, 000,000 (Mandatory in NH) If yes, describe under E.L. DISEASE -POLICY LIMIT 1 $1.000.000 DESCRIPTION OF OPERATIONS be. A Professional Liability 11/14/2011 1/14/2012 Per Claim $1, 000, 000 Claims Made �PR9695279 Annual Aggregate $3,000,000 DESCRIPTION OF OPERATIONS / LOCATIONS I VEHICLES (Attach ACORD 101, Additional Remarks Schedule, If more space Is required) If required by written contract or written agreement, the following provisions apply subject to the policy terms, conditions, limitations and exclusions: The Certificate Holder and Owner are included as Additional Insureds for ongoing and completed operations under General Liability, Automobile Liability, Umbrella / Excess Liability but only with respect to liability arising out of the Named Insured's work performed on behalf of the certificate holder and owner. This insurance will apply on a primary, non-contributory basis. A Blanket Waiver of Subrogation applies for General Liability, Automobile See Attached... City of Fort Collins Attn: Mark Laken P.O. Box 580 Fort Collins CO 8OS22 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHOR REPRESENTATIVE ACORD CORPORATION. All rights reserved ACORD 25 (2010105) The ACORD name and logo are registered marks of ACORD AGENCY Van Gilder Insurance Corp. POLICY NUMBER CARRIER AGENCY CUSTOMER ID: INTCON6 LOC #: ADDITIONAL REMARKS SCHEDULE 1J_IIYY@14 NAMED INSURED .nterwest Consulting Group .076 Lincoln Place loulder CO 80302 EFFECTIVE DATE: THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, FORM NUMBER: 25 FORM TITLE: CERTIFICATE OF LIABILITY INSURANCE Page I of I Liability, Umbrella/Excess Liability and workers' Compensation. Limited Contractual Liability is included. The Umbrella / Excess Liability policy provides excess coverage over the General Liability, Automobile Liability and Employers Liability. RE: P1124 Civil Engineering Annual Additional Insured: City of Fort Collins © 2008 ACORD CORPORATION. All rights The ACORD name and logo are registered marks of ACORD AC AZH CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDD/YYYY) II to zo11 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 NOTICONSTITUTE 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 CONM NATACT E:Kathy SLafz Van Gilder Insurance Corp. PHONE FAX 1515 Wynkoop, Suite 200 Ex0:303-837-8500 Ale No:303-831-52 5 E-MAIL ADDREss:kstarQvic.com Denver CO 80202 INSURER(S) AFFORDING COVERAGE NAIL# INSURERA:XL cl It Insurance CO. 7885 INSURED INTCON6 INSURER B:Travelers Property Casualty CO 5674 INSURER C:PL-Travelers Indemnity Cc of C 5682 Interwest Consulting Group INSURERD:The Phoenix Insurance Company 25623 1076 Lincoln Place Boulder CO 80302 -- INSURER E 41 INSURER F: COVERAGES CERTIFICATE NUMBER: 1522070527 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 ADDL INSR SUBR MD POLICYNUMBER POLICY EFF MM/DD/YYYY POLICY EXP MMIDDIYYYY LIMITS H GENERAL LIABILITY Y y 6807444M622 11/14/2011 1/14/2012 EACH OCCURRENCE $2, 000, 000 X COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED PREMISES(Eaoccurrence $1,000, 000 MED EXP(Any one person) $10, 000 CLAIMS -MADE ❑OCCUR PERSONAL& ADV INJURY $2,000,000 GENERAL AGGREGATE $4, 000, 000 GEN'L AGGREGATE LIMIT APPLIES PER'. PRODUCTS - COMP/OP AGO $4,000,000 I POLICY I^ PnT PRO n LOC $ C AUTOMOBILE LIABILITY Y Y BA7466M429 1/14/2011 1/14/2012 Ea acQcM 1, 000, 000 BODILY INJURY (Per person) $ ANY AUTO ALL UTOSS AOSCHEDULED AUUTOS NX BODILY INJURY (Peraccident) $ NON -OWNED HIRED AUTOS X AUTOS PROPERTY DAMAGE Per accident $ $ s X (UMBRELLA LIAB OGGUR Y Y CUP133OT262 11/14/2011 1/14/2012 EACH OCCURRENCE $1, 000, 000 AGGREGATE $11000, 000 EXCESS LIAB CLAIMS -MADE DEC I X I RETENTION$ 10, 000 $ B D WORKERS COMPENSATION AND EMPLOYERS' LIABILITY YIN ANY PROPRIETOR/PARTNERIEXECUTIVE OFFICER/MEMBER EXCLUDED? � NIA y �VMPJUB1339T93410 1341TO51 11/14/2011 11/14/2011 1/14/2012 1/14/2012 X WC SLIM U- OTH- T RV LIMIT _ E.L. EACH ACCIDENT $1, 000, 000 E.L. DISEASE -EA EMPLOYE $1, 000, 000 (Mandatory In NH) It yes, describe under E. L. DISEASE POLICY LIMIT 1 $1, 000, 000 DESCRIPTION OF OPERATIONS below A Professional Liability PR9695279 11/14/2011 1/14/2012 Per Claim $1, coo, 000 Claims Made Annual Aggregate $3, 000, 000 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required) If required by written contract or written agreement, the following provisions apply subject to the policy terms, conditions, limitations and exclusions: The Certificate Holder and Owner are included as Additional Insureds for ongoing and completed operations under General Liability, Automobile Liability, Umbrella / Excess Liability but only with respect to liability arising out of the Named Insured's work performed on behalf of the certificate holder and owner. This insurance will apply on a primary, non-contributory basis. A Blanket Waiver of Subrogation applies for General Liability, Automobile See Attached... City of Fort Collins Attn: Kyle Lambrecht PO Box 580 Fort Collins CO 80522 9_1CDJ 4 if W9 r LRl ri 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 ' —� ACORD 25 (2010/05) ne IgRR-9010 ACr1Rn The ACORD name and logo are registered marks of ACORD All rinhfe meer.md AGENCY CUSTOMER ID: INTCON6 LOC #: ADDITIONAL REMARKS SCHEDULE Page 1 of 1 AGENCY Van Gilder Insurance Corp. NAMED INSURED Tnterwest Consulting Group 1076 Lincoln Place Boulder CO 80302 POLICY NUMBER CARRIER NAIC CODE EFFECTIVE DATE: THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, FORM NUMBER: 25 FORM TITLE: CERTIFICATE OF LIABILITY INSURANCE ility, Umbrella/Excess Liability and Workers' Compensation. Limited Contractual Liability is uded. The Umbrella / Excess Liability policy provides excess coverage over the General Liability, mobile Liability and Employers Liability. tiion Insured: City of Ft. Collins, its officers, agents and employees. ACORD 1 © 2008 ACORD CORPORATION. All rights reserved. fhe ACORD name and logo are registered marks of ACORD