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HomeMy WebLinkAbout103265 HAISTON OIL COMPANY INC - INSURANCE CERTIFICATE (12)UP IU: KH ACORO° CERTIFICATE OF LIABILITY INSURANCE DATE(MINI 01I30I2013 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLYAND 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 endorsements . PRODUCER Phone: 970-635-9400 CONTACT PIES Insurance Group -JT 4648 Thompson Pkwy, Ste 200 Fax: 970-635-9401 Johnstown, CO 80534 John Hintzman 1 ti� PHONE FAX rvc No Ext: aC, No): E-MAIL ADDRESS: PRODUCER HAIST-1 CUSTOMER _to#: INSURERIS) AFFORDING COVERAGE NAICp INSURED Haiston Oil Company, Inc INSURER A: Nationwide Agribusiness Ins Co 128223 335 S Summit View Dr INSURERB:Pinnacol Assurance Co 141190 Fort Collins, CO 80524 INSURER L 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. PIEFF POLICY EXP LTR TYPE OF INSURANCE INSRAODLI SUBRVIVO I POLICY NUMBER MIN ICY YY Itudom—r LIMITS A GENERAL LIABILITY X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE XOCCUR X Waiver of Subrog CPP 107224A 02/01/2013 02/01/2014 EACH OCCURRENCE DAMAGEYO RENTED PREMISES -(Ea occurrence) $ 1,000,000 $ 100,000 MED EXP(Any one person) $ 5,000 PERSONAL & ADV INJURY $ 1,000,00( X Additional Ins GENERALAGGREGATE $ 2,000,00 GENE AGGREIG�ATE LIMIT APPLIES PER: X POLICY PIFCT RO- LOG PRODUCTS-COMP/OP AGG ( $ 2,000,00 lEmp Ben. $ 1,000,000 A AUTOMOBILE LIABILITY ANY AUTO ALL OWNED AUTOS SCHEDULED AUTOS HIREDAUTOS NON -OWNED AUTOS MCS 90 CA 107224A 02101/2013 02/91/2014 COMBINED SINGLE LIMIT (Ea accident) $ 1,000,00( X BODILY INJURY (Per person) $ BODILY NJURV (Per accitlenp $ PROPERTY DAMAGE (Per accitlenI) $ X X $ X $ A X UMBRELLA LIAB EXCESS LIAR X OCCUR CLAIMS -MADE CU 107224A 02/01/2013 0210112014 EACH OCCURRENCE $ 2,000,000 AGGREGATE $ 2,000,000 DeoucrlBLE RETENTION $ 10,000 $ X Is B WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE YIN OFFICERIMEMBER EXCLUDED' (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below NIA 3019023 02/01/2013 02/01/2014 WC STATU- OTH- X TCRY LIMITS ER E.LEACH ACCIDENT $ 500,000 E. L. DISEASE - EA EMPLOYEE $ 500,00 E.L. DISEASE - POLICY LIMIT 1 $ 500,000 DESCRIPTION OF OPERATIONS I LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required) CITYFTC City of Fort Collins Purchasing Department PO Box 580 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 bCrea��— CO 1988.2009 ACORD CORPORATION. All rights reserved. ACORD 25 (2009/09) The ACORD name and logo are registered marks of ACORD