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HomeMy WebLinkAbout102829 DON KEHN CONSTRUCTION INC - INSURANCE CERTIFICATE (6)Client#: 52210 8DONKEHN ACORD.., CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/Yl'YY( F 09/27/2012 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: Willis of Colorado, Inc. 720 South Colorado Boulevard Suite 60ON Ci Denver, CO 80246 ' O Zb PHONENo 303 722-7776 AX : 303-722$862 NC Est: AIC No E-MAIL ADDRESS: INSURER(S) AFFORDING COVERAGE NAIC # INSURER A, Pinnacol Assurance 41190 INSURED Don Kehn Construction, Inc. 6550 SCR5 INSURER B : INSURER C Fort Collins, CO 80528 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 NSRADDL SUSR MD POLICY NUMBER MOLDD EFF POLICY EXP MM DDIYYYV LIMITS GENERAL LIABILITY COMMERCIAL GENERAL LIABILITY CLAIMS -MADE OCCUR EACH OCECCURRENCE $ PREMISESOEaEoNccTu ence $ MED EXP (Any one person) $ PERSONAL S ADV INJURY $ GENERAL AGGREGATE $ GEN'L AGGREGATE LIMIT APPLIES PER: POLICY PRO LOG ECT PRODUCTS - COMPIOP AGG $ $ AUTOMOBILE LIABILITY ANY AUTO ALL OWNED SCHEDULED AUTOS AUTOS HIRED AUTOS NO1TOSWNED COMBINED SINGLE LIMIT Ea accident BODILY INJURY (Per Person) $ BODILY INJURY (Per accident) $ PPReOPPCEORT (DAMAGE S E UMBRELLA LIMB EXCESS LIAB OCCUR CLAIMS -MADE EACH OCCURRENCE $ AGGREGATE $ DED I I RETENTIONS $ A WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y / N ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? fi (Mandatory in NH) If yes, desrnbe under DESCRIPTION OF OPERATIONS below N/A 2093950 0/01/2012 10/01/2013 X I WCSTAZ OTH- EL EEL-- E.L. EACH ACCIDENT $500O00 E.L. DISEASE - EA EMPLOYEE $500 000 E.L. DISEASE - POLICY LIMIT s500,000 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, If more space is required) RE: Case #: 2012-CV-1477 City of Fort Collins 300 La Porte Avenue 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 ACORD 25 (2010/05) 1 of 1 #S973314/M973124 © 1988-2010 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD 8AKRE r1iar.Hb 59710 8DONKEHN ACORD,,. CERTIFICATE OF LIABILITY INSURANCE D0912712012YYI o9r2nzo12 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 Willis of Colorado, Inc. CONTACT NAME: PHONE 303 722-7776 PAX 303-722-8862 A!C No Ext : AIC, No 720 South Colorado Boulevard E-MAIL ADDRESS: INSURERS) AFFORDING COVERAGE NAIC # Suite 60ON INSURER A: Pinnacol Assurance 41190 Denver, CO 80246 L INSURED Don Kehn Construction, Inc. 6550 SCR5 Fort Collins, CO 80528 INSURER B : INSURER C INSRE NSUURERR ED : 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 CONTRACTOR 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 NSRADDLSUBR MID POLICY NUMBER MIDDPOLICEFF POLICMMIDDY EXP LIMITS GENERAL LIABILITY COMMERCIAL GENERAL LIABILITY CLAIMS -MADE F-IOCCUR EACH OCCURRENCE $ NTED PREMISE(Ea Eocccume es $ MED EXP (Anyone Person) $ PERSONAL & ADV INJURY $ GENERAL AGGREGATE $ GEN'LAGGREGATE LIMIT APPLIES PER: POLICY PEP LOC PRODUCTS - COMP/OP AGG $ $ AUTOMOBILE LIABILITY ANY AUTO ALL OWNED SCHEDULED AUTOS AUTOS NON -OWNED _ HIREDAUTOS AUTOS COMBINED SINGLE LIMIT Ea amdent $ BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ PROPERTY DAMAGE freer accident $ $ UMBRELLA LIAR EXCESS LIAB OCCUR CLAIMS -MADE EACH OCCURRENCE $ AGGREGATE $ DIED I I RETENTION $ $ A ANDEMPLOYERS' LIABILDY WORKERS COMPENSATION ANY PROPMETORIPARTNERIEXECUTIVE Y I N OFFICERIMEMBER EXCL., UDE? NJ IMandatory in NH) It yes, describe under DESCRIPTION OF OPERATIONS We. N!A 2093950 0/01/2012 10/01/201 X WCSTATU- OTH- E.L. F.ACH ACCIDENT $500OOO E.L. DISEASE - EA EMPLOYEE $500000 E.L. DISEASE -POLICY LIMIT s500,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101, Additional Remarks Schedule, It more space is roeulrod) Project Description: 6045 Asphalt Supply City of Fort Collins Administrative Services Purchasing Division PO 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 ACORD 25 (2010/05) 1 of 1 #S973215/M973124 © 1988-2010 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD 8AKRE