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HomeMy WebLinkAbout304997 BELFOR ENVIRONMENTAL INC - INSURANCE CERTIFICATE (3)�1 ® " o CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDD/YVYY) OBI,a,PD,P 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 Ann Risk Services Central, Inc. Southfield MI Office CONTACT PHONE FAX INC.No.EsC: (866) 283-7122 (qC. Nal; <84]) 053-5390 E-Mul ADDRESS: 3000 Town Center Suite 3000 INSURER(S) AFFORDING COVERAGE NAICe Southfield MI 48075 USA INSURED INSURER A: Pinnacol Assurance Company 41190 Be1fOr Environmental, Inc. SOTS Xal amath Street Denver CO 80221 USA INSURER a: Chartis Specialty Insurance Company 26883 INSURER C: National Union Fire Ins Cc of Pittsburgh 19445 INSURER D: Insurance Company of the State of PA 19429 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: 570045542146 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. Limits shown are as requested INSR LTR TYPE OF INSURANCE INSR MD POLICY NUMBER POLICY EFF MMmO PQLICYEXP MMD LIMITS C GENERAL LIABILITY GL EACH OCCURRENCE $1,000,000 SIR applies per policy terns & conch ions $1,000,000 X COMMERCIAL GENERAL LIABILITY PREMISES Ea occurrence CLAIMS -MADE ❑X OCCUR MED EXP(Anyone person) $100,000 PERSONAL 6 ACV INJURY $1,000,000 GENERALAGGREGATE $2,000, 000 GENL AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMPIOP AGG $2,000, 000 POLICY X PRO- X LOC C AUTOMOBILE LIABILITY CA 1707562 07 01 2012 07 01 2013 COMBINED SINGLE LIMIT Its accident) $1,000,000 BODILY INJURY( Per person) X ANY AUTO BODILY INJURY (Per accident) X ALL OWNED SCHEDULED AUTOS AUTOS NONOWNED PROPERTY DAMAGE X HIRED AUTOS AUTOS Per accident) X COI(DeJ$I'M X CcuPDsJ$IJ 00 C OCCUR 23102164 07/01/2012 07/01/2013 EACH OCCURRENCE $5,005,000 AGGREGATE $5,000,006 IUMBRELLALNB EXCESS UAB H CLAIMS -MADE DED RETENTION D WORKERS COMPENSATION AND wc035896312 07/01/2012 07/01/2013 WC STATU OTH- TORV LIMITS X ER EMPLOYERS'LU1BILnY YIN A05 E.L. EACH ACCIDENT $1,000, 000 A AN Y PRO PRIETORIPARTNER I EXECUnVE NIA 4051232 12/01/2011 12/O1/2012 OFFICERIMEMBER EXCLUDED? (Mandate, in NH) CO E L OISEASE-EA EMPLOYEE $1, 000, 000 Ry desnibe under DESCRIPTION OF OPERATIONS below EL DISEASE -POLICY LIMIT $1, 000,000 B Contractor Poll 04/01/2012 04/01/2013 Agg/OCC $15, 00(,000 I 7016851546 Deductible $100,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Allach ACORD 101, Addi4onal Remarks Schedule, Knees space is required) Re: Fort Collins ER Contract The City of Fort Collins is included as Additional Insured with respects to General Liability. waiver of Subrogation applies as required by contract. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED N ACCORDANCE WITH THE POLICY PROVISIONS. City of Fort Collins AUTHORRED REPRESENTATIVE Attn. James O'Neil II, CPPO,CPPB For North Mason, 2nd052 Floor e� l _ ��� P.O. BOX 580 c.(l-j/ Fort Collins CO 80522 USA ICtAE1CJ sDa ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25 (2010105) The ACORD name and logo are registered marks of ACORD L