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Home My WebLink About389648 A-1 CHIPSEAL COMPANY - INSURANCE CERTIFICATE (6)Alla- ® CERTIFICATE OF LIABILITY INSURANCE 9/26/2012 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 - .. Moody Insurance Agency, Inc.! --- - - -' 8055 East Tufts Avenue Suite 1000 Denver CO 80237 CONTACT Erin Threlkeld, CRIS NAME: PNONE . (303)824-6600 FAC No: (303)370-0318 EMAIL .ethrelkeld@moodyins. core INSURERS AFFORDING COVERAGE NA1C# INSURERA:Travelers Indemnity Company 5658 INSURED 4 A-1 Chipsea Company DBA: Rocky Mountain Pavement, LLC 2001 West 64th Ln Denver CO 80221 INSURER B:Travelers Prop Cas CO Of Amrc8 25674 INSURERC:Pinnacol Assurance 41190 INSURER D: INSURER E: 1 INSURER F: COVERAGES CERTIFICATE NUMBER:12-13 All Lines w/Forms 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 LTR rypE OF INSURANCE A DL UBR POLICY NUMBER POLICY EFF MMIOD POLICY EXP MM/DO LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 PREMISE Ea nee f 300,000 A X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE OCCUR $ DTC0019OP673PHX12 0/1/2012 0/1/2013 MED EXP(Any one peo $ 10,000 PERSONAL &ADV INJURY S 1,000,000 GENERAL AGGREGATE $ 2, 000;000 lditional Insured Endt GEN-L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 2,000,000 when required by contract POLICY X .PRO- ;LOC GD246 OB/OS attached':'/.. - $,- -. AUTOMOBILE LIABILITY .. .. _. ._ _ .. _ ... - .. _.. COMBINED SINGLE LIMIT Ea accident 11000,000 BODILY INJURY(Per person) $ B ANVAUTO ALLOWNED SCHEDULED AUTOS' AUTOSHIRED T810019OP673TIL12 0/1/2012 10/1/2013 Ix BODILY INJURY(Per accident) $ AUTOS .X AONOSWNED - PerOPERTYt DAMAGE $ $ ][ UMBRELLA LAB X OCCUR EACH OCCURRENCE $ 10,000,000 AGGREGATE $ 10,000,000 B EXCESS LAB CLAIMS -MADE DEO X RETENTION 10,00C $ VTSMCUP0190P673TIL12 0/1/2012 0/1/2013 C WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y / NFIR PROPRIETOR/PARTNERMXECUTNE OFFICENMEMBER EXCLUDED? (Mandalory in NH) NIA _ 4055760 0/1/2012 0/1/2013 X WC STATU- OTH "ITANY E.L. EACH ACCIDENT $ 500,000 E.L. DISEASE -EA EMPLOYE E 500,00 If yes, describe ur der DESCRIPTION OF OPERATIONS babe E.L. DISEASE -POLICY LIMIT E 500,000 DESCRIPTION OF OPERATIONS / LOCATIONS I VEHICLES (Anach ACORD 101, Additional Remarlm Schedule, if mom space is required) Re: 7417 Asphalt Surface Treatment Project The City of Fort Collins is included as an Additional Insured with respect to General Liability. 19702216534@efaxsend.com City of Fort Collins 300 Laporte Ave 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 Threlkeld, CRIS/CHIR ACORD 25 (2010/05) INWIlson'rur"n, The ArrYRn name and Inns ore rnnlaenr.A mark. nF arnan CORPORATION. All rights reserved_ COMMERCIAL GENERAL LIABILITY THIS ENDORSEMENT CHANdE* S THE POLICY. PLEASE READ IT CAREFULLY • BLANKET ADDITIONAL INSURED (CONTRACTORS) This endorsement modifies insurance provided under the following COMMERCIAL GENERAL LIABILITY COVERAGE PART 1. WHO IS AN INSURED — (Section II) is amended c) The insurance provided to the additional in- to include any person or organization that you sured does not apply to "bodily injury" or agree in a "written contract requiring insurance" "property damage" caused by "your work" to include as an additional insured on this Cover- and included in the "products -completed op - age Part, but: erations hazard" unless the "written contract a) Only with respect to liability for "bodily injury", requiring insurance" specifically requires you "property damage" or "personal injury"; and to provide such coverage for that additional insured, and then the insurance provided to b) If, and only to the extent that, the injury or the additional insured applies only to such damage is caused by acts or omissions of "bodily injury" or "property damage" that oc- you or your subcontractor in the performance curs before the end of the period of time for of "your work" to which the "written contract which the "written contract requiring insur- requiring insurance" applies. The person or ance" requires you to provide such coverage organization does not qualify as an additional or the end of the policy period, whichever is insured with respect to the independent acts earlier. or omissions of such person or organization. 3. The insurance provided to the additional insured 2. The insurance provided to the additional insured by this endorsement is excess over any valid and by this endorsement is limited as follows: collectible "other insurance", whether primary, a) In the event that the Limits of Insurance of excess, contingent or on any other basis, that is this Coverage Part shown in the Declarations available to the additional insured for a loss we exceed the limits of liability required by the cover under this endorsement. However, if the "written contract requiring insurance", the in- "written contract requiring insurance" specifically surance provided to the additional insured requires that this insurance apply on a primary shall be limited to the limits of liability re- basis or a primary and non-contributory basis, quired by that "written contract requiring in- this insurance is primary to "other insurance" surance". This endorsement shall not in- available to the additional insured which covers crease the limits of insurance described in that person or organization as a named insured Section III — Limits Of Insurance. for such loss, and we will not share with that b) The insurance provided to the additional in- "other insurance". But the insurance provided to sured does not apply to "bodily injury", "prop- the additional insured by this endorsement still is "other erty damage" or "personal injury" arising out excess over any valid and collectible in- surance", whether primary, excess, contingent or of the rendering of, or failure to render, any on any other basis, that is available to the addi- professional architectural, engineering or sur- tional insured when that person or organization is veying services, including: an additional Insured under such "other insur- i. The preparing, approving, or failing to ance". prepare or approve, maps, shop draw- 4. As a condition of coverage provided to the ings, opinions, reports, surveys, field or- additional insured by this endorsement: ders or change orders, or the preparing, approving, or failing to prepare or ap- a) The additional insured must give us written prove, drawings and specifications; and notice as soon as practicable of an "occur- ii. Supervisory, inspection, architectural or rence" or an offense which may result in a claim. To the extent possible, such notice engineering activities. should include: • CG D2 46 08 05 0 2005 The St. Paul Travelers Companies, Inc. Page 1 of 2 ACURH CERTIFICATE OF LIABILITY INSURANCE '101.1 DATE(MWDDNYYY) 9/26/2012 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 a . - - - - ---- ' - - PRODUCER Moody Insurance Agency, Inca - BOSS -East 'Tufts Avenue - Suite 1000 Denver CO 80237 CONTACT Erin Threlkeld,'CRIS .- NAME: PHONE (303)824-6600 - FAX .1303)370-0118 INC E"MAILEss.ethrelkeld®moodyins.com- - -- INSURERS AFFORDING COVERAGE'. - NAICa INSURERA:Travelers Indemnity Company 25658 INSURED A-1 Chipseal Company DBA: Rocky Mountain Pavement, LLC 2001 West 64th Ln Denver CO 80221 INSURERB:Travelers Prop Calls Co of Amrca 25674 I INSURER c:Pinnacol Assurance 41190 INSURER D: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER:12-13 All Lines w/Forma 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 LTfl TYPE OF INSURANCE POLICY NUMBER POLICY YYY MPOLICY DD YYY LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 11000,000 A X COMMERCIALGENERAL LIABILITY CLAIMS -MADE OCCUR X DTC0019OP673PEX12 0/1/2012 0/1/2013 DMAGE TO RENT PREMISES E ErDn $ 300,000 MED EXP (Ahl one person) $ 10,000 PERSONAL$ ADV INJURY $ 11000,000 GENERAL AGGREGATE $ 2,000,000 Additional Insured Endt GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP/OP'AGO $ " 2,000,000 when required by Contract - POLICY X PRO LOC CGD246 08/05 attached' �- AUTOMOBILE LIABILITY - Ea aciden SINGLE LIMIT 1.000 000 BODILY INJURY (Per person) $ B� X' ANY 'AUTO' ... _._ _ .... ALL OWNED SCHEDULED .X 'AUTOS AUTOS _... ....... .. -._. . --. .. T8100190P673TIL12 .. .. .. 10/1/2012 0/1/2013 BODILY INJURY accident) $ , PROPERTY (Per $ HIRED AUTOS X AUOTOSWNED _. _ . .. $ X UMBRELLA LIAR X OCCUR EACH OCCURRENCE $ 10,000,000 ..CLAIMS AGGREGATE $ 10,000,000 B EXCESS LIAR -MADE DED X RETENTIONS 10,000 1 $ PTSMCUP0190P673TIL12 0/1/2012 0/1/2013 C WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y/NCRY ANY PROPRIETOP/PARTNER/EXECUrIVE OFFICERIMEMBER EXCLUDED? O (Mandatory in NH) N/A 055760 10/1/2012 0/1/2013 X I WC STATUS I OTH- IT, E.L. EACH ACCIDENT $ - 500,000 E.L. DISEASE - EA EMPLOYEE $ 500,000 If yea, describe under DESCRIPTION OF OPERATIONS below. _... -._. _.. E.L. DISEASE -POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS / LOCATIONS/ VEHICLES (Attach ACORD 101, Additional Remarks Schedule, it more space is required) Re: 7256 Hot Applied Chipseal Overlay 2012 renewal The City of Fort Collins is included as an Additional Insured with respect to General Liability. City of Fort Collins 300 Laporte Ave 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 Threlkeld, CRIS/CHR F� ACORD 25 (2010/05) 01988-2010 ACORD INS025 (201005).01 The ACORD name and logo are registered marks of ACORD reserved. COMMERCIAL GENERAL LIABILITY THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. BLANKET ADDITIONAL INSURED (CONTRACTORS) This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART 1. WHO IS AN INSURED — (Section 11) is amended to include any person or organization that you agree in a "written contract requiring insurance" to include as an additional insured on this Cover- age Part, but: a) Only with respect to liability for "bodily injury", "property damage" or "personal injury"; and b) If, and only to the extent that, the injury or damage is caused by acts or omissions of you or your subcontractor in the performance of "your work" to which the "written contract requiring insurance" applies. The person or organization does not qualify as an additional insured with respect to the independent ads or omissions of such person or organization: 2. The insurance provided -to the additional insured by this endorsement is limited as follows: a) In the event that the Limits of Insurance of exceed the limits of liability required by the "written contract requiring insurance", the in- surance provided to the additional insured shall be limited to the limits of liability re- quired by that "written contract requiring in- surance". This endorsement shall not in- crease the limits of insurance described in - Section. tll.-.Limits Of Insur_ance_. b) The insurance provided to the additional in- sured does not apply to "bodily injury", "prop- erty damage" or "personal injury" arising out of the rendering of, or failure to render, any professional architectural, engineering or sur- veying services, including: I. The preparing, approving, or failing to prepare or approve, maps, shop draw- ings, opinions, reports, surveys, field or- ders or change orders, or the preparing, approving, or failing to prepare or ap- prove, drawings and specifications; and tt. Supervisory, inspection, architectural or engineering activities. c) The insurance provided to the additional in- sured does not apply to "bodily injury" or "property damage" caused by "your work" and included in the "products -completed op- erations hazard" unless the "written contract requiring insurance" specifically requires you to provide such coverage for that additional insured, and then the insurance provided to the additional insured applies only to such "bodily injury" or "property damage" that oc- curs before the end of the period of time for which the "written contract requiring insur- ance" requires you to provide such coverage or the end of the policy period, whichever is earlier. 3. The insurance provided to the additional insured by this endorsement is excess over any valid and collectible 'other insurance", whether primary, excess, contingent or on any other basis, that is • cover under this endorsement. However, if the "written contract requiring insurance" specifically requires that this insurance apply on a primary basis or a primary and non-contributory basis, this insurance is primary to "other insurance" available to the additional insured which covers that person or organization as a named insured for such loss, and we will not share with that _.-._"other insurance". But -the insurance provided to the additional insured by this endorsement still is excess over any valid and collectible 'other in- surance", whether primary, excess, contingent or on any other basis, that is available to the addi- tional insured when that person or organization is an additional insured under such "other insur- ance". 4. As a condition of coverage provided to the additional insured by this endorsement: a) The additional insured must give us written notice as soon as practicable of an 'occur- rence" or an offense which may result in a claim. To the extent possible, such notice • should include: CG D2 46 08 05 0 2005 The St. Paul Travelers Companies, Inc. Page 1 of 2