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HomeMy WebLinkAboutGRAY OIL CO INC - INSURANCE CERTIFICATECERTIFICATE OF INSURANCE ISSUED BY ASSOCIATION INSURANCE MARKETING, INC. PO BOX 68, EVERGREEN, CO 80437-0068 FAX 303 674 8819 303 674 8685 / 800 571 8685 Insured: GRAY OIL CO., INC. 804 DENVER AVENUE FT. LUPTON, CO 80621 TO WHOM IT CONCERNS: Company Affording Coverage PINNACOL ASSURANCE 7501 EAST LOWRY BLVD. DENVER, CO 80230 (303 361 4000) This is to certify that PINNACOL ASSURANCE has issued a Standard Workers' Compensation and Employers' Liability Policy as described below covering the liability imposed upon subject employers by the Workers' Compensation Act of Colorado, said policy being in good standing as of this certificate issue date: 01-18-12. POLICY NUMBER: 1350372 BROKER OF RECORD: BROKER CODE NUMBER630166 POLICY PERIOD: 02-01-12 to 02-01-13 ASSOCIATION INSURANCE MARKETING, INC. CLASSIFICATION: GASOLINE DEALER & D PO BOX 68 CODE: 88350 EVERGREEN, CO 80437-0068 LIMITS OF LIABILITY EMPLOYERS' LIABILITY COVERAGE Part Two of the policy, LIMIT OF EMPLOYERS LIABILITY, is as follows: Bodily Injury by Accident$1,000,000 each accident Bodily Injury by Disease $1,000,000 each employee Bodily Injury by Disease $1,000,000 policy limit .IMPORTANT: THE COVERAGE DESCRIBED ABOVE IS IN. EFFECT AS OF THE ISSUE DATE OF THIS CERTIFICATE. IT IS SUBJECT TO CHANGE AT ANY TIME IN THE FUTURE. CANCELLATION SHOULD THE ABOVE DESCRIBED POLICY BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF. PINNACOL ASSURANCE WILL ENDEAVOR TO MAIL 10 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER, BUT FAILURE TO MAIL SUCI4 NOTICE SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON PINNACOL ASSURANCE OR ASSOCIATION INSURANCE MARKETING. SPECIAL CONDITIONS: CERTIFICATE HOLDER CITY OF FORT COLLINS P.O. BOX 580 FORT COLLINS, CO 80522-0580 AUTHORIZED REPRESENTATIVE