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HomeMy WebLinkAboutJANSMA BROS EXCAVATING & TRUCKING - INSURANCE CERTIFICATEOP IU: SL , *c CERTIFICATE OF LIABILITY INSURANCE � UATDIYYYY) 05/04 OS/04/12 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 endorsements . PRODUCER 970-635-9400 PFS Insurance Group -JT 4848 Thompson Pkwy, Ste 200 970-635-9401 INTACT NAME: PHONE FAX A/C No Est : 'A/C No Johnstown, CO 8OS34 Tad BOrrett EMAIL -ADDRESS: PRODUCER JANSM-3 CUSTOMER ID N: INSURER(S) AFFORDING COVERAGE NAIC N INSURED _.a Jansma Bros. Excavating INSURER A: Mountain States Insurance Grp & Trucking Corp. 1475 Backhoe Road INSURERS; Pinnacol Assurance 1524210 Loveland, CO 80538 INSURER C : INSURER D : INSURER E INSURER F COVERAGES CERTIFICATE NUMBER: 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. LTR TYPE OF INSURANCE AOOLI WVD II NUMBER POLICPOLICY MMIDDY EFF MMVDDIVYYV LIMITS A GENERAL LIABILITY X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE 1XI OCCUR X Blanket Add'I Ins CPP0117096 04I01112 04I01/13 EACH OCCURRENCE DAMAGE TO RENTED PRENUSES(Eaoccurrence) $ 1,000,00 Is 100,000 MED EXP Any one person) I $ 10,000 PERSONALBADVINJURY $ 1,000,000 X Blanket Waiver GENERAL AGGREGATE $ 2,000,00 GEN'L AGGREGATE LIMIT APPLIES PER'. POLICY IRI- FrT n LOC PRODUCTS - COMP/OP AGG $ 2,000,00 8 A A A AUTOMOBILE LIABILITY ANY AUTO ALL OWNED AUTOS SCHEDULED AUTOS HIREDAUTOS NON -OWNED AUTOS BAP0117096 04101112 04I01/13 COMBINED SINGLE LIMIT (Ea accident) $ 1,000,000 X BODILY INJURY (Per person) $ I BODILY INJURY (Per accident) $ PROPERTY DAMAGE (Per accident) $ X X $ $ A UMBRELLA LIAR EXCESS LIAB X OCCUR CLAIMS -MADE UMB0117096 04/01/12 04/01113 EACH OCCURRENCE $ 1,000,000 AGGREGATE $ 1,000,000 DEDUCTIBLE RETENTION $ $ $ B WORKERS COMPENSATION AND EMPLOYERS'LIABILITY V/N ANY PROPRIETOR/PARTNERIEXECUTIVE OFFICER/MEMBER EXCLUDED? (Mandatory In NIq If yes, describe under DESCRIPTION OF OPERATIONS below NIA 2342390 BLANKET WAIVER OF SUBRO 06/01/12 06/01/13 WC STATU-I IIOTH- X TORY LIM ITSLLER $ 100,000 EL. EACH ACCIDENT EL DISEASE -EA EMPLOYEE $ 100,000 E.L. DISEASE -POLICY LIMIT 1 $ 500,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space Is required) L OPERATIONS — ALL LOCATIONS. FORT CO City of Fort Collins 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 EPp -- ©1988-2009 ACORD CORPORATION. All rights reserved. ACORD 25 (2009/09) The ACORD name and logo are registered marks of ACORD