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ACORD. CERTIFICATE OF LIABILITY INSURANCE
DA7E(MMI00/YYYY)
1/11/2012
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 endomement(s).
PRODUCER
CONTCT
NAME,
PNHcN E,t,303-534-4567 ac,Nq:303-534-0600
Signature Select LLC
EMAIL
ADDRESS:
17th Street Suite 600
INSURERS) AFFORDING COVERAGE
NAIC #
Denver, CO 80202
INSURER A: Westfield Insurance Company
24112
INSURED
Hillside Construction Inc
537 Highland Place Rd
Fort Collins, CO 80524
INSURER B :
INSURER C
INSURER D:
INSURER E
INSURER F:
COVEF AGES CERTIFICATE NUMBER! REVISION NUMI3tK:
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 CONTRACTOR 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
AOOL
INSR
SUB
WVD I
POLICY NUMBER
POLICY EFF
MMIOD
POLICY E%P
MM O
UMITS
A
GENERAL LIABILITY
X COMMERCIALGENERALLIABILITY
CLAIMS -MADE 5XI OCCUR
CWP5761087
1/24/2012
01/24/2013
$1 000 000
❑EACH�OCCURRENCE
PREMISES EaEomERDnce
$300000
MED EXP (Any one person)
$10 000
PERSONAL & ADV INJURY
$1 000 000
GENERAL AGGREGATE
E2,000,000
GENT AGGREGATE UMIT'APPLIES PER:
X POLICY PRO-JECI LOC
PRODUCTS-COMPIOP AGO
s2,000,000
$
AUTOMOBILE LIABILITY
ANY AUTO
ALL OWNED SCHEDULED
AUTOS AUTOS
NON -OWNED
HIRED AUTOS AUTOS
(E..COMld.M)NED SINGLE LIMIT
Ea accitlent
BODILY INJURY IPer person)
$
BODILY INJURY (Per accident)
$
PROPERTY DAMAGE
Per accident
$
UMBRELLA LIAB
EXCESS LIAB
OCCUR
CLAIMS -MADE
EACH OCCURRENCE
$
AGGREGATE
S
DED RETENTIONS
$
WORKERS COMPENSATION
AND EMPLOYERS' LABILITY YIN
ANY PROPRIETOR/PARTNER/EXECUTNE --1
OFFICERIMEMBER EXCLUDED?
(Mandatory In NH)
I( yes, describe under
OE SCRIPTION OF OPERATIONS Below
N/A
WC STATU- OTH.
ITS ER
EL EACH ACCIDENT
$
E.L. DISEASE- EA EMPLOYEE
5
EL. DISEASE -POLICY LIMIT
E
DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLE$ (Attach ACORD 101, Additional Ratnarks Schedule, It mm apace is required)
City of Fort Collins SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
tY THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
PO Box 580 ACCORDANCE WITH THE POLICY PROVISIONS.
Fort Collins, CO 80522-0580
AUTHORIZED REPRESENTATIVE
V 1SBB-2U1U AIJUKU OUKYVKAI IVN. All ngnSs reserveG.
ACORD 25 (2010/05) 1 of 1 The ACORD name and logo are registered marks of ACORD
#S785415/M785407 NRH