HomeMy WebLinkAbout114340 CUSTOM SERVICES OF COLORADO INC - INSURANCE CERTIFICATE (2)"""R" CERTIFICATE OF LIABILITY INSURANCE
DATE(MMIDD/YYYY)
03/25/2012
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 endorsement(s).
PRODUCER
CONTACT NAME: Karole Peters
Ewing -Leavitt Insurance Agency
4025 St. Cloud Dr.
NCNNn Eat: 970.679.7355 (AIAC,No):866.237.2178
ADDRESS: karole-peters@leavitt.com
Suite 100
Loveland, CO 90538
PRODUCER QQQQO549
CUSTOMERIDp:
INSURERS) AFFORDING COVERAGE
NAICM
INSURED
INSURER A: Sell Insurance
22543
Custom Services of Colorado, Inc.
INSURERB: Pinnacol Assurance
41190
796 Abrams Wy
INSURER C:
Loveland, CO 80537
INSURER D:
INSURER E :
INSURER F :
COVERAGES CERTIFICATE NUMBER: 12-13 Renewal 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 REOUIREMENT, 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
ABBE
I N S R
SUBR
WVD
POLICY NUMBER
POLICY EFF
MMIDDIYYYY
POLICY EXP
MMIDDIYYYY
LIMITS
A
GENERAL LIABILITY
X COMMERCIAL GENERAL LIABILITY
CLAIMS -MADE rX] OCCUR
X Blkt Al Insd
20-TC-0003160361-203/29/2012
03/29/2013
EACH OCCURRENCE
$ 1,000,00
PREMISES TDAMAGE O RENTEDence
$ 100,000
MED EXP (Any one person)
$ 5,00
PERSONAL B ADV INJURY
$ 1,000,00
X Blkt Waiver of Sub
GENERAL AGGREGATE
$ 2,000,00
GEN'L AGGREGATE LIMIT APPLIES PER:
PoLICV JE� LOC
PRODUCTS - COMP/OP AGG
$ 2,000,00
$
A
AUTOMOBILE
LIABILITY
ANY AUTO
ALLOW AUTOS
SCHEDULED AUTOS
HIREDAUTOS
NON-OWNEDAUTOS
20-A-003160362-2'03/29/2012
0312912013
a accident COMBINED SINGLE LIMIT
E
$ 1, 000,00
X
BODILY INJURY (Per person)
8
BODILY INJURY (Per accident)
$
PROPERTY DAMAGE
(Per accident)
$
X
X
$
$
A
X
UMBRELLA LIAR
EXCESS LAB
X
OCCUR
CLAIMS -MADE
20-CU-003160363-2
0312912012
0312912013
EACH OCCURRENCE
$ 1,000,00
AGGREGATE
$ 1,000,00
DEDUCTIBLE
RETENTION $' 10, 00C
$
X
$
B
WORKERS COMPENSATIONAND EMPLOYERS' LIABILITYyIN
ANY PROPRIETORIPARTNER/EXECUTIVE
OFFICERIMEMBER EXCLUDED? O
(Mandatory In NH)
If yes, describe under
DESCRIPTION OF OPERATIONS below
N I A
4025555i 01101/2012
BLANKET WAIVE
OF SUBROGATIO
01/01/2013
X TWOFY LIMITS OER
E.L. EACH ACCIDENT
$ 1,000,0Q
E.L. DISEASE - EA EMPLOYEE
$ 1,000,00
E.L. DISEASE - POLICY LIMIT
$ 1, Q00, OQ
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101, Additional Remarks Schedule, If more space Is required)
ity of Ft. Collins is shown as additional insured as respects General Liability
�s_mI nvn. I cZ nvLv�n L.AINI CLLAI IUIN
City of Ft. Collins
256 W. Mountain Avenue
P. 0. Box 580
Ft., Collins, CO 80522-0580
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
K"i
ACORD 25 (2009/09) The ACORD name and logo are registered marks of ACORD
All riahts reserved