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Home My WebLink AboutROBERTS EXCAVATION CORPORATION - INSURANCE CERTIFICATE (8)From: Lisa Prewitt FaxID:(970) 484-4165 Page 1 o12 Date:5/172013 04:02 PM Page of 2 ROBER-7 OP ID: LID CERTIFICATE OF LIABILITY INSURANCE 05117 DAT) 05/17 /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: 970A82-7747 CONTACT Brown &Brown Inc Fax: 970A84-4165 4532 Boardwalk Dr, Suite 200 Fort Collins, CO 80525 Shanna M Jamsay PHONE PAX A/C No Eet: A/C, No): EMAIL ADDRESS INSURER(S) AFFORDING COVERAGE NAICi INSURER A: Westfield Insurance Company 24112 INSURED Roberts Excavation Corporation INSURER B: Pinnacol Assurance Company 41190 Attn: Gerald Roberts 1801 1 st Street INSURER C: Berthoud, CO 80513 INSURER D: INSURER E INSURER F COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS 15 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 CR 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 INSR WVO POLICY NUMBER POLICY EFF MM,DDM'YY POLICY EXP MMIDD/YYYY LIMBS GENERAL LIABILITY EACH OCCURR ENCE $ 1,000,000 A X COMMEROIPLGENERALLIABILITY CWP7548279 04101113 04/01/14 ES( N ED PREMISES Ea occumnce 8 500,00 CLAIMS -MADE Fx1OCCIIR -PREMISES MEDIX (Any one person) $ 15,00 PERSONAL &ADV INJJRV $ 1,000,00 GENERAL AGGREGATE $ 2,000,00 GEN'L AGGREGATE LIMIT APPLIES PER PRODUCTS-COMP/)P AGG $ 2,000,00 PRO- LOC POLICY [XI AUTOMOBILE LIABILITY COMBINEDIS IN GLE LIMIT $ 1,000,00 BODILY IN.uRv (PerpersgN $ A X ANY AUTO CWP7548279 =01113 04/01/14 ALL OWNED SCHEDULED AUTOS AUTOS BODILY INJJRY (Per ec6tlentl $ PROPERTY DAMAGE Perealdent $ NON -OWNED HIREDAUTOS AUTOS $ X Hired Auto X Prop Damag - X UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 1,000,000 A EXCESS LIAB CLAIMSMADECWP7548279 04101/13 04/01/14 AGGREGATE $ 1,000,00 DED X RETENTION$ 0 $ WORKERS COMPENSATION WC STATU- OTH- B AND EMPLOYERS' LIABILITY ANY PROPRIETOR/PARTNERIEXECUTIVE Y/" 3241433 06/01113 06/01/14 EL. EACH ACCIDENT $ 1,000,00 OFFICERIMEMBER EXCLUDED' ❑ (hand at., in NH) N/A EL DISEASEEAEMPLOYEE $ 1,000,00 It yes descube under DESCRIPTION OF OPERATIONS below EL.DISEASE - POLICY LIMB $ 1,000,00 A Leased/Rented Eq CWP7548279 04/01/13 04/01/14 Lsd/Rntd 400,00 Ded 1,00 DESCRIPTION OF OPERATIONS / LOCATIONS /VEHCLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required) Fax# 221-6707 CITYF10 City of Fort Collins 215 N. Mason St. Fort Collins, CO 80521 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZZEEDD REPRESENTATIVE HO ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25 (2010/05) The ACORD name and logo are registered marks of ACORD