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HomeMy WebLinkAbout468473 VEOLIA ES TECHNICAL SOLUTIONS LLC - INSURANCE CERTIFICATE (6)CERTIFICATE HOLDER © 1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25 (2010/05) AUTHORIZED REPRESENTATIVE CANCELLATION CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DD/YYYY) JECT LOC POLICY PRO- GEN'L AGGREGATE LIMIT APPLIES PER: CLAIMS-MADE OCCUR COMMERCIAL GENERAL LIABILITY GENERAL LIABILITY PREMISES (Ea occurrence) $ DAMAGE TO RENTED EACH OCCURRENCE $ MED EXP (Any one person) $ PERSONAL & ADV INJURY $ GENERAL AGGREGATE $ PRODUCTS - COMP/OP AGG $ DED RETENTION $ CLAIMS-MADE OCCUR $ AGGREGATE $ UMBRELLA LIAB EACH OCCURRENCE $ EXCESS LIAB DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required) INSR LTR TYPE OF INSURANCE POLICY NUMBER POLICY EFF (MM/DD/YYYY) POLICY EXP (MM/DD/YYYY) LIMITS WC STATU- TORY LIMITS OTH- ER E.L. EACH ACCIDENT E.L. DISEASE - EA EMPLOYEE E.L. DISEASE - POLICY LIMIT $ $ $ ANY PROPRIETOR/PARTNER/EXECUTIVE If yes, describe under DESCRIPTION OF OPERATIONS below (Mandatory in NH) OFFICER/MEMBER EXCLUDED? WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y / N AUTOMOBILE LIABILITY ANY AUTO ALL OWNED SCHEDULED HIRED AUTOS NON-OWNED AUTOS AUTOS AUTOS COMBINED SINGLE LIMIT BODILY INJURY (Per person) BODILY INJURY (Per accident) ACORD 101 (2008/01) The ACORD name and logo are registered marks of ACORD © 2008 ACORD CORPORATION. All rights reserved. THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, FORM NUMBER: FORM TITLE: ADDITIONAL REMARKS ADDITIONAL REMARKS SCHEDULE Page of AGENCY CUSTOMER ID: LOC #: AGENCY CARRIER NAIC CODE POLICY NUMBER NAMED INSURED EFFECTIVE DATE: Policy Term: 07/01/2013 - 01/01/2014� Employers Liability Disease-Policy Limit: $1,000,000� � Policy Term: 07/01/2013 - 01/01/2014� 2 2 Employers Liability Disease-Each Employee: $1,000,000� Employers Liability Disease-Policy Limit: $1,000,000� Houston Policy Number: C84631302� Carrier: Insurance Company of the State of PA � Employers Liability Each Accident: $1,000,000� Policy Term: 07/01/2013 - 01/01/2014� �� �� � Additional Workers' Compensation Policies� Certificate of Liability Insurance Employers Liability Disease-Policy Limit: $1,000,000� 010056 � Policy Number: WC84631303� Employers Liability Each Accident: $1,000,000� Carrier: The Insurance Company of the State of PA� Employers Liability Disease-Each Employee: $1,000,000� Employers Liability Each Accident: $1,000,000� Employers Liability Disease-Each Employee: $1,000,000� *Marsh USA, Inc.� 9131 East 96th Avenue� Veolia ES Technical Solutions, LLC� Henderson, CO 80640 Policy Number: WC84631304� �� 25 Carrier: The Insurance Company of the State of PA� PROPERTY DAMAGE $ $ $ $ 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 ADDL WVD SUBR N / A $ $ (Ea accident) (Per accident) 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). The ACORD name and logo are registered marks of ACORD COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: INSURED PHONE (A/C, No, Ext): PRODUCER ADDRESS: E-MAIL FAX (A/C, No): CONTACT NAME: NAIC # INSURER A : INSURER B : INSURER C : INSURER D : INSURER E : INSURER F : INSURER(S) AFFORDING COVERAGE SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. B 5,000,000 01/01/2014 GL4572700 Manashi Mukherjee WC1558356 (FL) HOU-001838688-24 1,000,000 WC6517888 (CA) 07/01/2013 19429 of Marsh USA Inc. Attn: veolia.certrequest@marsh.com / 212.948.5053 N 07/01/2013 X 5,000,000 07/01/2013 N/A B 8 01/01/2014 B 38318 01/01/2014 01/01/2014 CA4576281 (AOS) B 5,000,000 CH12XENOA2P58NC 5,000,000 WC6517889 (MA, WI, Mono) 19445 Insurance Company Of The State Of PA 1,000,000 X X 07/01/2013 08/08/2013 HEN-TS 07/01/2013 07/01/2013 City of Fort Collins, its officers, agents and employees are included as Additional Insured (except as respects all coverage afforded by the Workers' Compensation policy) as required by written contract, but only for liability arising out of the operations of the named insured. 01/01/2014 07/01/2013 215 North Mason� City of Fort Collins� Starr Indemnity & Liability Company P.O. Box 580� D X CA4576283 (VA) C B National Union Fire Insurance Co 010056-ES-GAWX-13-14 10,000 01/01/2014 7,500,000 01/01/2014 B CA4576282 (MA) Fort Collins, CO 80522 36056 1,000,000 1,000,000 WC6517886 (AOS) 1717 Arch Street� *Marsh USA, Inc.� Philadelphia, PA 19103�� X 9131 East 96th Avenue� Veolia ES Technical Solutions, LLC� Henderson, CO 80640 07/01/2013 Attn: Ed Bonnette, CPM� Purchasing Division� 07/01/2013 07/01/2013 01/01/2014 B 01/01/2014 N/A SISCSEL01840512 01/01/2014 A Navigators Specialty Insurance Company