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HomeMy WebLinkAbout432111 BUILDER SERVICES GROUP INC DBA ALLIED INSUL - INSURANCE CERTIFICATE-1 ® " o CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) D6/26/2D,8 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 endorsement(s). PRODUCER Aon Ri SIt Services Central, Inc. Southfield MI Office CONTACT NAME: A/C.NNo. Ext): (866) 283-7122 aC. No.): (847) 953-5390 E­MWL ADDRESS: 3000 Town center suite 3000 INSURER(S) AFFORDING.COVERAGE NAIC # Southfield MI 48075 USA -L 11 INSURED INSURER A: old Republic Ins CO 24147 Builder Services Group, Inc. d/b/a Allied Insulation A Masco corporation company INSURER B: ACE American Insurance Company 22667 INSURER C: Indemnity Insurance Co of North America 43575 6617 S College Ave. Fort Collins co 80525 USA INSURERD: National union Fire ins Co of Pittsburgh 19445 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: 570050022863 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. Limits shown are as requested LTR TYPE OF INSURANCE INSR WVD POLICY NUMBER MMIDDfYYYYI (MWDDNYYYI LIMITS A GENERAL LIABILITY MWZY EACH OCCURRENCE $2,000,000 SIR applies per policy terns & condi ions AMA $2,000,000 X COMMERCIAL GENERAL LIABILITY PREMISES Ea occurrence CLAIMS -MADE X❑ OCCUR MED EXP(Any one person) $25,000 PERSONAL &ADV INJURY $2,000,000 GENERAL AGGREGATE $5,000,000 GEN'LAGGREGATELIMIECTT APPLIES PER: PRODUCTS - COMP/OP AGG $10,000,000 X POLICY PRO- LOC A AUTOMOBILE LIABILITY MwTS 18398-13 06/30/2013 06/30/2014 COMBINED SINGLE LIMIT Ea accident $5,000,000 BODILY INJURY ( Per person) X ANY AUTO BODILY INJURY (Per accident) ALL OWNED SCHEDULED AUTOS AUTOS NON -OWNED PROPERTY DAMAGE X HIRED AUTOS X AUTOS Per accident D X UMBRELLA LAB X OCCUR 20562116 06/30/2013 06/30/2014 EACH OCCURRENCE $2,000,000 SIR applies per policy terns & condi ions AGGREGATE $2,000,000 EXCESS LIAR CLAIMS -MADE DED X RETENTION C WORKERS COMPENSATION AND WLRC47320641 06/30/2013 06/30/2014 WC STATU- OTH- X TORY LIMITS ER EMPLOYERS' LIABILITY YIN Ded - AOS E.L. EACH ACCIDENT $1,000,000 B ANY PROPRIETOR/PARTNER/EXECUTIVE NIA _ WLRC4732063A 06/30/2013 06/30/2014 OFFICER/MEMBER EXCLUDED? (Mandatory in NH) Ded - CA, MA E.L. DISEASE -EA EMPLOYEE $1, 000, 000 Il yes, describe under DESCRIPTION OF OPERATIONS below ' E.L. DISEASE -POLICY LIMIT $1-, 000 , OOO B Excess WC WCUC47320677 06/30/2013 06/30/2014 Retention $2,000,000 SIR applies per policy ter In s & condi ions Statutory Limit Included DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule. If more space is required) [Proj: RE: Project Name: 215 N. Mason, job Site: 215 N. Mason, Fort Collins, Co.] [AI: City of Fort Collins] is included as an Additional insured with respect to the General Liability and Automobile Liability policies, as required by written contract. CERTIFICATE HOLDER CANCELLATION 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 AUTHORIZED REPRESENTATIVE Attn: Insurance Administrator PO Box Collins580 � O. '� — ^ "L Fort llico 80522 USA v)�TnrLi-i/cp (C,l�.b/a ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25 (2010/05) The ACORD name and logo are registered marks of ACORD AGENCY CUSTOMER ID: 570000027887 LOC #: 4 ADDITIONAL REMARKS SCHEDULE Page _ of _ AGENCY Aon Risk Services Central, Inc. NAMEDINSURED Builder Services Group, Inc. ' POLICY NUMBER See Certificate Number: 570050022863 CARRIER See Certificate Number: 570050022863 NAIC CODE EFFECTIVE DATE: ADDITIONAL REMARKS THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, FORM NUMBER: ACORD 25 FORM TITLE: Certificate of Liability Insurance INSURER(S) AFFORDING COVERAGE NAIC # INSURER INSURER INSURER INSURER ADDITIONAL POLICIES If a policy below does not include limit information, refer to the corresponding policy on the ACORD certificate form for policy limits. INSR LTR TYPE OF INSURANCE ADDL IX,SR SUBR R'1VD POLICY NUMBER POLICY EFFECTIVE DATE MM/DD POLICY EXPIRATION DATE M/DD LIMITS WORKERS COMPENSATION B N/A SCFC47320653 WI Only 06/30/2013 06/30/2014 C N/A WLRC47320665 TX Only 06/30/2013 06/30/2014 ACORD 101 (2008101) C 2008 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD CERTIFICATE OF LIABILITY INSURANCE DATE(MWDD/YYYY) DS/25,2D,3 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 endorsement(s). PRODUCER AOn Risk Services central, Inc. Southfield MI Office CONTACT NAME: (A/C NNo. Exq: (866) 283-7122 (FAX No.): (847) 953-5390 E-MAIL ADDRESS: 3000 Town Center suite 3000 INSURERS) AFFORDING COVERAGE NAIL # Southfield MI 48075 USA INSURED INSURER A: Old Republic Ins CO 24147 Builder Services Group, Inc. d/b/a Allied insulation A Masco Corporation company INSURER B: ACE American Insurance Company 22667 INSURERC: indemnity insurance Co Of North America 43575 INSURERD: National union Fire Ins co of Pittsburgh 19445 6617 5 College Ave. Fort Collins CO 80525 USA INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: 570050022863 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. Limits shown are as requested LTR TYPE OF INSURANCE INSR WVD POLICY NUMBER MM/DD LIMITS A GENERAL LIABILITY MWZY RFD EACH OCCURRENCE $2,000,000 SIR applies per policy terns & condi ions DAMAGE TO K $2,000,000 X COMMERCIAL GENERAL LIABILITY PREMISES Ea ocanence MED EXP (Any one person) $25 , 000 CLAIMS-MADE X❑ OCCUR PERSONAL &ADV INJURY $2,000,000 GENERAL AGGREGATE $5,000,006 GE N'L AGGREGATE LIMIT APPLIES PER PRODUCTS - COMP/OP AGG $10,000,000 X POLICY PRO- LOC JECT A AUTOMOBILE LIABILITY MWTB 18398-13 06/30/2013 0630 2014 COMBINED SINGLE LIMIT Ea accident $S,000,OOO BODILY INJURY ( Per person) ANY AUTO BODILY INJURY (Per accident) ALL OWNED SCHEDULED AUTOS AUTOS IX PROPERTY DAMAGE X HIRED AUTOS X NON -OWNED Per accident AUTOS D X UMBRELLA LIAB OCCUR 20562116 06/30/2013 06/30/2014 EACH OCCURRENCE $2,000,000 H SIR applies per policy terns & condi ions AGGREGATE $2,000,000 EXCESS LIAR CLAIMS -MADE DED X RETENTION C WORKERS COMPENSATION AND WLRC47320641 06/30/2013 06/30/2014 X 7yORY LSTATU IMITS FORTH EMPLOYERS' LIABILITY YIN Ded - ADS E.L. EACH ACCIDENT $1,000,000 B ANY PROPRIETOR/PARTNER/EXECUTIVE NIA WLRC4732063A 06/30/2013 06/30/2014 OFFICERIMEMBER IiXCLUDEDI (Mandatory In NH) Ded - CA, MA E.L. DISEASE -EA EMPLOYEE $1,000,000 H yes, describe under DESCRIPTION OF OPERATIONS be. E.L DISEASE -POLICY LIMIT $1, 000, 006 B Excess WC wcuc47320677 06/30/2013 06/30/2014 Retention $2,000,000 SIR applies per policy ter ns & condi ions statutory Limit Included DESCRIPTION OF OPERATIONS I LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, H more space is required) [Pro,: RE: Project Name: 215 N. Mason, lob Site: 215 N. Mason, Fort Collins, CO.] [AI: City of Fort Collins] is included as an Additional Insured with respect to the General Liability and Automobile Liability policies, as required by written contract. CERTIFICATE HOLDER CANCELLATION 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 I AUTHORIZED REPRESENTATIVE Attn: Insurance Administrator Po Box Fort Collinsli CO 80522 USA 7%L�ii-i/cp `Gbf/zGt`a%4p ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25 (2010/05) The ACORD name and logo are registered marks of ACORD AGENCY CUSTOMER ID: 570000027887 LOC #: A ADDITIONAL REMARKS SCHEDULE Paae of AGENCY Aon Risk Services Central, Inc. NAMEDINSURED Builder Services Group, Inc. POLICY NUMBER See Certificate Number: 570050022863 CARRIER See Certificate Number: 570050022863 - NAIC CODE EFFECTIVE DATE: ADDITIONAL REMARKS ACORD 101 (2008/01) ® 2008 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD