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HomeMy WebLinkAboutEVANS TRUCKING LLC - INSURANCE CERTIFICATE (2)05-31-3535839-2 Shelter Mutual Insurance Company 1817 W Broadway W� Columbia, MO 65218 1-800-SHELTER (743-5837) General Liability Insurance Policy Declarations ***MANUAL DEC*** Named Insured: BRUCEREVANS GUewriS 7r'ltc1,.�01 LLe Policy Number: 05-31-3535839-2 6490 N COUNTY ROAD 3 Effective Date: 03/06/2013 (03:54 P.M. CST) FORT COLLINS CO 80524-9304 Expiration Date: 08/29/2013 (12:01 A.M. CST) Notice to the Mortgagee/Loss Payee/Add] Insured: Your interest will be continuous until cancellation notice is mailed to you. Business of the Named Insured: HAULS DIRB/ROCK Limits of Insurance General Aggregate (Other Than Products — Completed Operations) Products — Completed Operations Aggregate Limit (See Each Classification Below) Personal And Advertising Injury Limit Each Occurrence Limit Rented To You Limit Medical Expense Limit Agent: BRUCE JOHNSON AGENCY INC 05-5549-10 PO BOX 270663 FORT COLLINS CO 80527 970-226-5034 The Named Insured is a(n): Audit Period: Individual Annually $2,000,006 Included $1,000,000 $1,000,000 $100,000 Any One Premises $5,000 Any One Person 99793 TRUCKERS PAYROLL PER $1000 6.674 $168.00 INCLUDING PRODUCTS &/OR COMPLETED OPERATIONS $25,200 ITEM ZIP CODE: 80524 PREMISES & OPERATIONS- 88801 PREMIUM CHARGE FOR REINSURANCE OF $500,000 $938.00 OCCURRENCE, EXCESS OF $500,000 OCCURRENCE. ITEM ZIP CODE: 80524 6490 N COUNTY ROAD 3 FORT COLLINS CO Total for Term (This is Not a Bill): $1,174.00 Policy formsand additional endorsements attached to this policy.. °' _ � '-`=� t w;_ Number _� ;_ Commercial General Liability Coverage Form CG 00 01 1207 Addl Insd-Owners, Lessees Or Contractors-Sched Person Or Org MARTIN MARIETTA CG 32 29 06 10 Lessees Ur Contractors-Sched Person Or Org Bivens "Trucking And CG 32 29 06 10 Excavating Recording And Distribution Of Material Or Information In Violation Of Law Exclusion CG 00 68 05 09 rungi Ur Bacteria Exclusion CG 21 67 12 04 Addl Insd-Owners, Lessees Or Contractors-Sched Person Or Org Connell Resources Inc CG 32 29 06 10 gl Page I 05-31-3535839-2 Add[ Insd-Owners, Lessees Or Contractors-Sched Person Or Org City Of Fort Collins CG 32 29 06 10 Total Pollution Exclusion Endorsement CG 2149 09 99 Exclusion - Exterior Insulation And Finish Systems CG 21 86 12 04 Exclusion - Year 2000 Computer -Related & Electronic Problems CG 2160 98 98 Mutual Policy Notifications S-18-S Amendatory Endorsement (Pollution Exclusion) G-252-G Non -Binding Arbitration CG 24 01 12 04 Employment -Related Practices Exclusion CG 21 47 12 07 Lead Poisoning Exclusion Endorsement B-601-B Asbestos Exclusion B-559-B Nuclear Energy Liability Exclusion Endorsement (Broad Form) IL 00 21 09 08 IL U226 U9 U/ Exclusion - Damage To Work By Subcontractor On Your Behalf CG 22 94 10 01 AddPlnsured MARTIN MARIETTA MATERIALS 2710 WYCLIFF RD RALEIGH NC 27607-3033 Adlnsured_„__._ dl CITY OF FORT COLLINS PO BOX 580 FORT COLLINS CO 80522-0580 (For Office Use Only) Transaction: PC SL H.O. CODE: 1,174.00 Policy ID: 66004218766 Policy Term: One Year G-2. I 0-G 21 44 07 98 Addllnsured _ !3,E BIVENS TRUCKING AND EXCAVATING 862 W WILLOX LN FORT COLLINS CO 80524-1147 Date Issued: 03-08-2013 ' 11272012' Add[ Insured__ CONNELLRESOURCESINC 5150 SE FRONTAGE RD FORT COLLINS CO 80528-9526 End of Declarations g] Page 2