HomeMy WebLinkAboutEVANS TRUCKING LLC - INSURANCE CERTIFICATE05-31-3535839-2
Policy Issued By
Shelter Mutual Insurance Co.
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Columbia,
Broadway � Columbb ia, MO 65218-0001
I MON I 1-800-SHELTER, 1-800-743-5837
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Named Insured:
BRUCE R EVANS
6490 N COUNTY ROAD 3
FORT COLLINS CO 80524-9304
Notice to the Mortgagee/Loss Payee/Addl Insured: Your interest
will be continuous until cancellation notice is mailed to you.
***MANUAL DEC***
General Liability Insurance
Policy Declarations
Agent:
BRUCE JOHNSON AGENCY INC
PO BOX 270663
FORT COLLINS CO 80527
AGENT #: 05-05549-10
PHONE: 970-226-5034
Policy Number: 05-31-3535839-2 Effective Date: November 21, 2012, 1:54 PM Central Time
Policy Form Number: CG 00 01 12 07 Expiration Date: Auguat 29, 2013, 12:01 A.M. Central Time
Business of the Named Insured: HAULS DIRT/ROCK
The Named Insured is a(n): Individual
Audit Period: Annually
Limits of Insurance
General Aggregate (Other Than Products — Completed Operations) $2,000,000
Products — Completed Operations Aggregate Limit (See Each Classification Below) Included
Personal And Advertising Injury Limit $1,000,000
Each Occurrence Limit
Rented To You Limit
Medical Expense Limit
99793 TRUCKERS
INCLUDING PRODUCTS &/OR COMPLETED OPERATIONS
ITEM ZIP CODE: 80524
PREMISES & OPERATIONS-
88801 PREMIOUM CHARGE FOR REINSURANCE OF $500,000
OCCURRENCE, EXCESS OF $500,000 OCCURRENCE.
ITEM ZIP CODE: 80524
6490 N COUNTY ROAD 3 FORT COLLINS CO
Additional information on next page
(For Office Use Only)
Transaction: P.C.
H.O. CODE: 1,157.00
Policy Term: One Year
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$1,000,000
$100,000 Any One Premises
$5,000 Any One Person
PAYROLL PER $1,000 6.674
$25,200
Total For Term (This Is Not A Bill):
$168.00
$938.00
$1,157.00
Date Issued: 11-27-2012
10222012' Countersigned By 61 i (�
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