Loading...
HomeMy WebLinkAboutCONEJO AZUL INC - INSURANCE CERTIFICATE (2)-it1 y20 5/30/2013 3:50 PM FROM: Fax Welsh Insurance Agency Inc TO: 19702216782 PAGE: 001 OF 002 acoRo� CERTIFICATE OF LIABILITY INSURANCE DA05/30/13"n PRODUCER Welsh Insurance Agency, Inc. THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE 4033 Boardwalk Drive, Suite #200 HOLDER. THIS CERTIFICATE DOES NOTAMEND, EXTEND OR Fort Collins, CO 80525 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. INSURERS AFFORDING COVERAGE NAIC # Phone (970) 206-1810 Fax (970) 206-1808 INSURED COOefO AZU,Inc. INSURER A: AUTO -OWNERS INSURANCE CO 808 W. MOUNTAIN AVE. INSURER B' INSURER C: Fort Collins, CO 80521 INSURER D: INSURER E. COVERAGES INSURER F. THE POLICIES OF INSURANCE LISTED HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OFANY CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OF MAY PERTAIN. THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR LTR ADD'L INSRD TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE DATE MMMDNY 'POLICY EXPIRATION DATE MMMDNY LIMITS GENERAL LIABILITY EACH OCCURRENCE 500,000 © COMMERCIAL GENERAL LIABILITY 74926439 08/28/12 08/25/13 DAMAGE TO RENTED PREMISES Ea occurence 300,000 MED EXP(Any one Person) 10,000 ❑❑CLAIMS MADE ©OCCUR A ❑ ❑ PERSONAL BADVINJURY 500,000 GENERAL AGGREGATE 1,000,000 ❑ GENT AGGREGATE LIMIT APPLIES PER PRODUCTS-COMP/OPAGG 1,000,000 © POLICY ❑ PROJECT ❑ LOG AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT ❑ ANYAUTO _ (Ea accident) BODILY INJURY (Per person) ❑ ❑ ALL OWNED AUTOS ❑ SCHEDULED AUTOS ❑ HIRED AUTOS ❑ NON OWNED AUTOS BODILY INJURY (Per accident) ❑ PROPERTY DAMAGE (Per accident) GARAGE LIABILITY UTO ONLY -EA ACCIDENT THER THAN EAACC �ALITO ❑ ❑ ANY AUTO ❑ ONLY: AGG EXCESSIUMBRELLA LIABILITY EACH OCCURRENCE AGGREGATE ❑ OCCUR ❑ CLAIMS MADE ❑ ❑ DEDUCTIBLE ❑ RETENTION $ WORKERS COMPENSATION AND ❑ WC STATU- ❑ OTH. EMPLOYERS' LIABILITY TORY LIMITS FIR E.L. EACH ACCIDENT ANY PROPRIETOR l PARTNER I EXECUTIVE OFFICER / MEMBER EXCLUDED? Iryes, desuibe under SPECIAL PROVISIONS below E.L. DISEASE - EA EMPLOYEE E.L. DISEASE- POLICY LIMIT OTHER DESCRIPTION OF OPERATIONS/ LOCATIONS I VEHICLES / EXCLUSIONS ADDED BY ENDORSEMENT/ SPECIAL PROVISIONS HOT DOG STAND CERTIFICATE HOLDER CANCELLATION City of Fort Collins - PURCHASING DEPARTMENT Attn: Purchasing Department 215 North Mason FORT COLLINIS, CO 80524 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 10 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR REPRESENTATIVES. AUTHORIZED REPRESENTATIVE © ACORD CORPORATION 1988 5/30/2013 3:50 PM FROM: Fax Welsh Insurance Agency Inc TO: 19702216182 PAGE: 002 OF 002 IMPORTANT If the certificate holder is an. ADDITIONAL INSURED, the policy(ies) must be endorsed. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). 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). DISCLAIMER The Certificate of Insurance on the reverse side of this form does not constitute a contract between the issuing insurer(s), authorized representative or producer, and the certificate holder, nor does it affirmatively or negatively amend, extend or alter the coverage afforded by the policies listed thereon. ii1YL➢LRU:1i.1] 6/4/2013 11:44 AM FROM: Fax Welsh insurance Agency Inc TO: 1 970 221-6707 PAGE: 002 OF 003 AUTO -OWNERS INS.CO. Page 2 55040(11/87) Issued. 07-10-2012 AGENCY WELSH INSURANCE AGENCY INCCompany :POLICY NUMBER 024632-74926439-12 32-0068-00 MKT TERR 100 Bill INSURED CONEJO AZUL INC Term 06-28-2012 to 08-28-2013 COMMERCIALGENERALLIABILITY COVERAGE -- LIMITS OF INSURANCE General Ag3re.gate $1,0001000 (Other han Products -Completed Operations) Produets,C ompisted Operations Aggregate 1,000,000 Personal Injury And Advertising Injury 500,000 .Eacn C,ccu;repcs 500,000 Commercial General Liability Plus Endorsement Damage to Premises Rented to You 300,000. Any. One Premises (Fire, Lightning Explosion, Smoke or Water Damage) Medical . Payments 10000 Any One Person Hired Auto & Non -Owned Auto. 500:000 Each Occurrence Expanded Coverage Details See Form: Extended Watercraft Personal Inju;rry Extension Groadener. Suppleman(ary Payirnents Stuadened Khowladge Of occurrence Additions PfOducis-Completed:Cperations Aggregate B tan tre; Acdllionel Ins'urec. - Lessor off Leased Equipment Bian.k.et Addltipnal Insured-. - Managers or -Lessors of -Premises Newly Formed qr Acquired Organizations Extension Blahk:el Waiv=r of Subrpgetiori - Twice the "General Aggregate Limit", shown above, is provided at no additional charge for each 12 month period in accordance with form 55300. AUDIT TYPE: Annual .Audit 55:Ra6 MS THAT (06-04yAPPLY. CG24071(O C�gfi) 5530035(07(05)0f)) IL00(12(11-85)04) IC00(02(11-85) 55091 (10-06) 55296 (09-09) LOCATION OF PREMISES YOU OWN, RENT OR OCCUPY LOC 001 BLDG 001 518 Whedbee St Fort Collins, CO 80524-3132 TERRITORY: 002 COUNTY: Larimer Classification Subline CODE 00501 CommercialGeneralLi-ab-ility Plus Prem/Op Endorsement Included At 7.5°/ Of The Premises Operation Premium Premium Basis Rates Premium Prem/Op Prem Inc Inc Inc 6/4/2013 11:44 AM FROM: Fax Welsh Insurance Agency Inc TO: 1 970 221-6707 PAGE: 003 OF 003 ItAuto-low wrs Page 3 - 55040 (11/87) INSURANCE -0OMPANY Issued 07-10-2012 6701 ANACAPRI BL'VD:., LANSING, MI 48917;39.99 TAILORED PROTECTION POLICY DECLARATIONS AGENCY WELSH INSURANCE AGENCY INC Renewal Effective 08-28-2012 32-0068-00 MKT -TERR 100 (970) 206-1810 POLICY NUMBER 024632-74§26439-12 INSURED CONEJO AZUL INC DBA BLIND BROTHERS :BUSINESS Fcoaess 808 W MOUNTAIN AVE Company POLICY TERM B-ilpl y 12:01 a.m. 1201 a.m. FORT COLLINS, CO 80521-2508 08-28-2012to 08-28-2013 In consideration of pa yrnen. of 'Ihd premluM ShP.Yn below, this Declareli0ns antl' ally uhmeo sls 10 pur yolieg,, ','I F.yjd. have Policy is renewed. Please VICIMn this an questions,Please consult:wirh your agent. COMMERCIAL GENERAL LIABILITY COVERAGE ' CODE 16902 Restaurants - With :No Sate Of. Prem/Op Gross Sales Each 1000 40,000 Alcoholic Beverages - WithoutProd/Comp Op Seating. 1.740 $70.00 40,000 1.184 $47,00 ,Additional Interests CODE.49950 Schad Add'L Ins-Excl Prod/Cops Prem/Op Flat Charge City Of Fort 'Collins > - Downtown Business Prem/Op Fiat Charge City Of Loveland Prem/Op Flat Charge TERRORISM - CERTIFIED ACTS SEE FORM ,5935,0, 55405, 59390' $d 8.00 $18.00. S 18.00 $2.00 LOCATION 001 -PREMIUM $173.00 6/4/2013 11:44 AM FROM: Fax Welsh Insurance Agency Inc TO: 1 970 221-6707 PAGE: 002 OF 003 AUTO -OWNERS INS. CO. Page 2 55640 (11/87.) Issued. 0.7-10-2012 AGENCY WELSH INSURANCE AGENCY INCCompany .POLICY NUMBER024632.74926439-12 32-0068-00 MKT TERR 100 Bil'I ixsugeo CONEJO AZUL INC Term 08-28-2012 to 08--28-2013 COMMERCIAL --GENERAL -LIABILITY COVERAGE LIMITS OF INSURANCE General Aggregate (Other Ihan Products -Completed Operations) $1,.000.000 Products, Comps eted Operations Aggregate P ars0ral Injury And Advertising I.njucy 1.000,000 O.ccu.rranlce 500.000 _Eac^ 500,000 Commercial General Liability Plus Endorsement Damage to Premises Rented to You (Fire, Lightning, Explosion, Smoke or Water 300,000. Any One Premises Damage) Medical .Payments Hired Auto &Non -Owned Auto 10.000 Any One Person500:000 Each Occurrence Expanded Coverage De -tails See Form: Extended Watercraft Perscnal In):ury Extension 6readenae Supplementary payments HusnronaIF'-rocucis-Compieced.O.perations Aggregate Bla:^.,.k-e Additional Insured: Lessor of Ceased Equipment Blanket Addltionvl Insured: - Managers orLessorsof Premises Newly Formed pr Acquired OrgOiiations Extension 816rik81 'Wa'.i'.ver of Twice the '"General Aggregate Limit", shown above, is provided at no additional charge for each 12 month period in accordance with form 65300. AUDIT TYPE: Annual -Audit FORMS THAT APPLY. TO THIS COVERAGE: 59350 (01:-.08) IL0021 (11-85) IL0017'(1.1 :-85) 55146 (0- 604) C7 (0.1-96) 55300 (07-05) 55202_ (1293:19 (02=06) 55091 ) 5296(09-09) -04J 5 LOCATION OF PREMISES YOU OWN, RENT OR OCCUPY LOC 001 BLDG 00.1 518 Whedbee St Fort C-ollins, CO 80524-3132 TERRITORY: 002 COUNTY: Larimer Classification Subline Commercial -General Li'abCOD E 005001us Endorsement Included At 7.5u Of Prem/Op The PremisesOperation Premium - Premium Basis Rates Premium Premlop Prem Inc Inc Inc 6/4/2013 11:44 AM FROM: Fax Welsh Insurance Agency Inc TO: 1 970 221-6707 PAGE: 003 OF 003 t4uto-owywrs Page 3 55040 (11/87) INSURANCE COMPANY Issued 07-10-2012 6101 ANACAPRI BLVD.. LANSING, MI 48917-3.9.99 TAILORED PROTECTION POLICY DECLARATIONS AGENCY WELSH INSURANCE AGENCY INC Renewal Effective-08-28-2012 32.0068-00 MKT TERR 100 (970) 206-1810 POLICY NUMBER 024632-74926439.12 INSURED CONEJO AZUL. INC DBA BLIND BROTHERS .BUSINESS ADDRESS 808 W MOUNTAIN AVE Company B'i I Comp POLICY TERM- E12:01 a.m. 12:01 a mFORT COLLINS, CO 80521-2508 .28-2012to 08-28 2013 In consideration of payment o! the prpmfyM sNa•.va De clorations and'alta chmelw IC :halo w, Ih is' ;I f,!yov. policy is renewed. Plesse aftuch- this rcur policy"', have any questions,_. please consult.: wish vour a goril COMMERCIAL GENERAL LIABILITY COVERAGE ' CODE16902 Restaurants - With No Sale Of. Prem/Op Gross Sales 40.000 Each 1000 Alcoholic Beverages - Without Seating. Prod/Comp Op 40,000 1.740 1.164- $70.00 $47.00 . Additional Interests CODE49950 Schad Add'L Ins-Excl Prod/Cops Prem/Op Ci.tY Or Fort 'Collins Downtown Business Prem/Op City Of Loveland Prem/Op Flat Charge Fiat Charge Flat Charge TERRORISM - CERTIFIED ACTS 'SEE FORM 5935.0, 55405. 59390- LOCATION 001 PREMIUM $18.00 $18,00. $18.00 $2.00 $173.00