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HomeMy WebLinkAboutROBERTS EXCAVATION CORPORATION - INSURANCE CERTIFICATE (7)From:Morgan Fugate FaxID:(970) 484-4165 Page 1 of 2 Date:4/1/2013 04:29 PM Page:1 of 2 ROBER-7 OP ID: FM ,4�o�Ro CERTIFICATE OF LIABILITY INSURANCE DATE(101113 1 04101 /13 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 endorsements . PRODUCER Phone:970482-7747 CONTACT NAME: Brown & Brown Inc 4532 Boardwalk Dr, Suite 200 Fax: 970484-4165 Fort Collins, CO 80525 Sharma M Jamsay PHONE FAX AIC No Est: (AIO, No): E-MAIL ADDRESS: INSURER(S) AFFORDING COVERAGE NAIC # INSURERA: Westfield Insurance Company 24112 INSURED Roberts Excavation Corporation INSURER : Pinnacol Assurance Company 41190 Attn: Gerald Roberts 1801 1 st Street INSURER C Berthoud, CO 80513 INSURER D: INSURER E 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. INSR TR TYPE OF INSURANCE POLICYNUMBER MMIDDV EFF MMIDDPOLICY EXP M'YY LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 1,000,00 A X COMMERCIAL GENERAL LIABILITY CWP7548279 04/01/13 04/01/14 DAMAGE TO RENTED PREMISES (Ed occurrence) $ SOO,OO CLAIMS -MADE FxI OCCUR MED FAR (Any one person) $ 15,00 PERSONAL & ADS INJURY $ 1,000,00 GENERAL AGGREGATE $ 2,000,00 GEN'L AGGREGATE LIMIT APPLIES PER PRODUCTS - COMP/OPAGO $ 2,000,00 JETT17 POLICY X PRO- LOC $ AUTOMOBILE LIABILITY COMBINED SINGLE LINT I (Ed accident) $ 1,000,00 X BODILY INJURY (Per person) $ A ANY AUTO CWP7548279 04/01/13 04/01/14 ALL OWNED F 1 SCHEDULED AUTOS AUTOS BODILY INJURY (Per accident) $ PROPERTY DAMAGE (Per accident) $ NON -OWNED HIRED AUTOS AUTOS X UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 1,000,00 AGGREGATE $ 1,000,00 A EXCESS LIAB CLAIMS -MADE CWP7548279 04/01/13 04/01/14 DED X RETENTION 0 $ B WORKERS COMPENSATION AND EMPLOYERS'LIABILITY IN ANY PROPRIETowPARTNEP/EXECUTIVE Y 3241433 06/01 /12 06/01 /13 X WCSTATU OTH- TORY LIMITS ER E.L. EACH ACCIDENT $ 1,000,00 OFFICERMEMBER EXCLUDED? (Mandatory in NH) NIA E. L. DISEASE - EA EMPLOYEE $ 1,000,00 If yes describe under DESCRIPTION OF OPERATIONS below EL.DISEASE -POLICY LIMIT $ 1,000,00 A Leased/Rented Eq CWP7548279 04/01 /13 04/01/14 Lsd/Rntd 400,00 Ded 1,00 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required) ax# 221-6707 CERTIFICATE HOLDER CANCELLATION CITYF10 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. City Of Fort Collins 215 N. Mason St. AUTHORIZED REPRESENTATIVE Fort Collins, CO BOS21 Sharma M Jamsay © 1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25 (2010/05) The ACORD name and logo are registered marks of ACORD From:Morgan Fugate FaxID:(970) 484-4165 Page 2 of 2 Date:4/1/2013 04:29 PM Page:2 of 2 (RORAGE 2 NOTEPAD I INSURE D'S NAME Roberts Excavation Corporation ID: FM OP D: FM DATE 04/01/13 The following apply if required by written contract: ercial General Liability ket Additional Insured - Ongoing Operations - Form CG3227 0610 ket Additional Insured - Completed Operations - Form CG7133 0211 ary & Non -Contributory Coverage - Form CG7055 1298 ket Waiver of Subrogation - Form G7094 0805 Project Aggregate - Form CG2503 0509 Location Aggregate - Form CG2504A 0509 al Automobile: Additional Insured - Form CA7078 0911 Waiver of Subrogation - Form CA0444 0310 ers Compensation: ket Waiver of Subrogation - Form 359b is following form.