HomeMy WebLinkAbout103265 HAISTON OIL COMPANY INC - INSURANCE CERTIFICATE (7)UP IU: KH
ACOROR
CERTIFICATE OF LIABILITY INSURANCE . _ - -
DATE (MMIDDIYYYY)
o1127/12
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 970-635-9400
PFS Insurance Group -JT
4848Thompson Pk 970-635-9401
Wy, Ste 20D
Johnstown, CO 80534
John Hintzman
CONTACT
NAME:
PHONE FAX
AICIL Ezt: (PC, No),
E-MAIL
ADDRESS,
CPRODUCER HAIST•1
USTOMER o p:
INSURERS AFFORDING COVERAGE
NAIL
INSURED Haiston Oil Company, Inc
- Jeff Haiston
INSURERA: Nationwide Agribusiness Ins Co
28223
INSURER B: Pinnacol Assurance Co
524210
INSURER C:
335 S Summit View Dr
Fort Collins, CO 80524
INSURER 0:
INSURER E
NSURER F
ono.
COVERAGES C i l It I l i rvInrcii -----------
BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED
TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT
WITH RESPECT TO
WHICH THIS
INDICATED. NOTWITHSTANDING ANY REQUIREMENT,
INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL
THE TERMS,
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
INSR AD WeR POLICY EFF POLICY EXP
TYPE OF INSURANCE POLICY NUMBER MMIDDIYYYY MMIDOIYYYY
LIMITS
LTR
GENERAL LIABILITY
EACH OCCURRENCE $
1,000,00
A X COMMERCIAL GENERAL LIABILITY CPP 107224A 02/01/12 02/01/13
AMA TOR ED
PREMISES Ea occurrence $
100,00
MED EXP(Any one person) $
5,00
CLAIMS -MADE ❑X OCCUR
X Waiver of Subrog
PERSONAL It ADV INJURY $
1,000,00
X Additional Ins
GENERALAGGREGATE $
2,000,00
PRODUCTS - COMPMP AGG $
2,000,00
GEN-L AGGREGATE LIMIT APPLIES PER
Emp Ben. $
1,000,00
X POLICv PRO LOC
COMBINED SINGLE LIMIT
$ 1,000,00
AUTOMOBILE
LIABILITY
(Ea accident)
A
ANY AUTO
CA 107224A
02/01N2
02/01113
X
BODILYNJURV(par Person)
$
BODILY INJURY (Per accident)
$
ALL OWNED AUTOS
PROPERTY DAMAGE
S
SCHEDULED AUTOS
(Per accitlen
X
HIREaccident)
X
NON-OWNEDAUTOS
X
MCS 90
X
UMBRELLA LIAR X OCCUR
EACH OCCURRENCE
$ 1,000,00
AGGREGATE
$ 1,000,00
Excess LIAR Cl-AIMS-MADE
AIMS -MADE
CU 107224A
02/01/12
02/01/13
A
$
DEDUCTIBLE
X RETENTION $ 10,000
X RV LIMWC IT
$
WORKERS COMPENSATION __-_ _
E.U. EACH ACCIDENT
$ .. 500,00
AND EMPLOYERS' LIABILITY-
Y�
-'
3019023
02/01/12
02/01N3
B
ANY PROPRIETORIPARTNERIEXECUTIVE
NIA
500,00
OFFICER/MEMBER EXCLUDED?
(Mandatory in Ni
EL DISEASE - EA EMPLOYEE
$
500,00
If yes, describe under
DESCRIPTION OF OPERATIONS below
EL DISEASE - POLICY LIMIT
$
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required)
CITYFTC
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
City of Fort Collins
Purchasing Department AUTHORIZED REPRESENTATIVE
PO Box 580
Fort Collins, CO 80522
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ACORD 25 (2009109) The ACORD name and logo are registered marks of ACORD