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HomeMy WebLinkAbout471395 J A R CONCRETE LLC - INSURANCE CERTIFICATE (4)A�� �® CERTIFICATE OF LIABILITY INSURANCE 7/3/2oi2 "' 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' _ Firt'Mainstreet Insurance, LLC NAME: CONTACT Debbie Brickham PHONE (303)776-5122 "' FAX No :,.(303)076-5495' EbMDAfiESS:dbrickham@FirstMainStreet.com - 275 S. Main Street, Sui_t_e .100 INSURERS AFFORDING COVERAGE NAICIN - P.O. Box 847 INSURER A:OWners' Ins Co/Auto Owners Longmont CO 80502 INSURED L-1, ASS INSURER B:Plnnacol Assurance INSURERC: J.A.R. Concrete, LLC INSURER D: DBA J.A.R. Holdings, LLC INSURER E: 11621 Weld County Road, 13 INSURER F: Longmont CO 80504 COVERAGES CERTIFICATE NUMBER:12/13 Revised 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. INSR R TYPE OF INSURANCE ADOL UBR POLICY NUMBER MMIODn YYV) fMM/DDP`YYYI LIMITS GENERAL LIABILITY EACH OCCURRENCE 8 1,000,000 x COMMERCIAL GENERAL LIABILITY PREMISES Ea occurrence) $ 50,000 A CLAIMS -MADE OCCUR 74586182 /1/2012 /1/2013 MED EXP(Any one person) $ 5,000 PERSONAL & ADV INJURY $ 1,000,000 - GENERAL AGGREGATE .$ 2,000,000 �. GENT AGGREGATE LIMIT APPLIES PER PRODUCTS-COMP/OP AGG $. 2,000,000 _ -_ $ X POLICY PRO- LOC AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Eaacciden 1 000 000 BODILY INJURY (Per person) $ A ANY AUTO ALL OWNED X SCHEDULED AUTOS AUTOS NON -OWNED X. HIREDAUTOS X AUTOS I$ 758618200 /1/2012 /1/2013 BODILY INJURY (Per accident) $ PROPERTY DAMAGE Par accitlent Uninsured motorist Bl-sin le $ 1 000 000 UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 1,000,000 AGGREGATE $ 1,000,000 A EXCESS LIAB CLAIMS-IAADE DIED I RETENTION$ 10, 00 $ 758618201 /1/2012 /1/2013 $ WORKERS COMPENSATION X WC STATU- OTH- TST IMITS AND EMPLOYERS' LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE YIN E. L. EACH ACCIDENT $ 1 000,000 OFFICER/MEMBER EXCLUDEDY (Mandatory, in NH) NIA 0 ]2304 - /1; 2012 9/1/2013 EL DISEASE - EA EMPLOYE �$ - 1 000,000 EL. DISEASE -POLICY LIMIT $ 1 000 000 f yes, describe under DESCRIPTION OF OPERATIONS below DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD iD1, Additional Re Larks Schedule, if more space is required) City of Fort Collins as additional insured with respect to general liability per Form 55372, when required by written contract. ■nacuoL�evacw�aac� (970)221-6707 City of Fort Purchasing & P O Box 580 Fort Collins, SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Collins Risk Management AUTHORIZED REPRESENTATIVE CO 80522-0580 Debbie Brickha n/tM@4 ACORD 25 (2010/05) INS025 (201005).01 ©1988-2010 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD A`� h® CERTIFICATE OF LIABILITY INSURANCE 7/3/2012 "' 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 First Mainstreet Insurance, LLC 275 S. Main Street, Suite 100 P.O. BOX 847 Longmont CO 80502 CONTACT Debbie Bri Ckharn NAME: PHONE (303) 776-5122 AAC No: (303)776-5495 Ep AIE ,cibrickham@ FirStMaiRStreet. corn INSURERS AFFORDING COVERAGE NAIC fI INSURERA:Owners Ins CO/Auto Owners INSURED J.A.R. Concrete, LLC DBA J.A.R. Holdings, LLC 11621 Weld County Road, 13 Longmont CO 80504 INSURER B:Pinnacol Assurance INSURER C: INSURER D: INSURERE: INSURER F: COVERAGES CERTIFICATE NUMBER:12/13 Revised 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. INSR TR TYPE OF INSURANCE A DDLSUBR POLICY NUMBER MMILO /YYYY MMIDDNYYY LIMITS A GENERAL LIABILITY X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE aOCCUR 74586182 /1/2012 /1/2013 EACH OCCURRENCE S 1,000,000 PREMISES Es occurrence $ 50,000 MED EXP(Any one person) $ 5,000 PERSONAL 8 ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER. X POLICY PRO LOC IFCT PRODUCTS - COMPIOP AGO $ 2,000,000 $ AH AUTOMOBILE LIABILITY ANY AUTO ALL OWNED X SCHEDULED AUTOHREDSAUTOS AUTOS X AUTOS NON-OWNED 758618200 /1/2012 /1/2013 COMBINED SINGLE LIMIT Ea accident 1,000,000 BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ PeDauba DAMAGE $ Uninsured motorist Bl-single $ 1,000,000 A UMBRELLA LAB EXCESS LABCLAIMS-MADE X OCCUR 758618201 /1/2012 /1/2013 EACH OCCURRENCE $ 1,000,000 AGGREGATE $ 1,000,000 DED RETENTIONS 10,00 $ B WORKERS COMPENSATION AND EMPLOYERS' LIABILITY IN ANY PROPRIETOR/PARTNER/EXECUTIVE Y❑ OFFICER/MEMBER EXCLUDED? (Mandatory in NH) If yes desuibe under DESCRIPTION OF OPERATIONS below N/A I 072304 /1/2012 /1/2013 X WC STATI OTH- E.L. EACH ACCIDENT $ 1 000 000 E.L. DISEASE - EA EMPLOYE $ 1 000 000 E.L. DISEASE -POLICY LIMIT S 1 000 000 DESCRIPTION OF OPERATIONS I LOCATION$ I VEHICLES (Attach ACORD 101, Additional Rvnarks Schedule, if more space is required) (970)224-6134 City of Fort Collins Building 6 Zoning Dept Contractors Licensing P 0 Box 580 Fort 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 REPRESENTATIVE Brickham/MMM ©1988-2010 ACORD CORPORATION. All rights reserved. INS025 (201005).01 The ACORD name and logo are registered marks of ACORD