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HomeMy WebLinkAbout131163 ADECCO INC - INSURANCE CERTIFICATE (2)ACORO® CERTIFICATE OF LIABILITY INSURANCE DATE IMMID0810112013DIYYYY) 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 terns 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 endorsemenri PRODUCER Marsh USA, Inc. 1166 Avenue of the Americas CONTACT NAME: -WCNI1e.EXtl FAX No: E-MAIL ADDRESS: New Yak, NY 10036 Attn: Adecco.Certs@matsh.com Fax: 212-948-0018 INSURER(S) AFFORDING COVERAGE NAIC N INSURER A: AXA Insurance Company 33022 370044-ALL-STAND-13-14 NO INSURED Adecc' o j 175 Broad 75 tl Hollow Road INSURER B : National Union Fire Insurance Co Of Pittsburgh 19445 INSURER c :Insurance Company Of The State Of PA 19429 INSURER o : New Hampshire Insurance Company 23841 Melville, NY 11747-4902 INSURER E INSURER F: COVERAGES CERTIFICATE NUMBER: NYC-006676075-01 REVISION NUMBER:1 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. LICY EFF POLICY EXP IR ADDLTYPE OF INSURANCE INSR SUER IDDIYYYY LTR POLICY NUMBER MMMMIDDNYYY LIMITS LT A GENERAL LIABILITY PCS002071(13) GaI0112013 01/0112014 EACH OCCURRENCE $ 2,000,000 X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE OCCUR OAMAACE-ACE PREMISES Ea occurrence $ 2,000,000 MED EXP (Any we person) $ N/A PERSONAL S ADV INJURY $ 2,000,000 GENERAL AGGREGATE $ 4,000,000 GENT AGGREGATE LIMIT APPLIES PER. PRODUCTS - COMPIOP AGG $ 4,000,000 X POLICY X PRO- X LOC $ B AUTOMOBILE LIABILITY X CA 5196216(ADS) 0110112013 0110112014 COMBINED SINGLE LIMIT Ea accidenn $ 2000000 X BODILY INJURY (Per person) $ B ANY AUTO CA 5196218(MA) 0110112013 01/01/2014 ALL OWNED SCHEDULED AUTOS AUTOS BODILY INJURY (Per academ) $ NON -OWNED HIRED AUTOS AUTOS H PROPERTY DAMAGE IPer accident)$ $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ AGGREGATE $ EXCESS LIAB CLAIMS -MADE OLDRETENTION $ C D C WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y / N ANY PROPRIETOR/PARTNERRXECUTIVE OFFICEMMEMBER EXCLUDED? (Mandatory in NH) NIA WC018112601 (AOS-30 STATES) WC018112602 (AOS-12 STATES) WC018112605(MA ,ND,WA,WI,WY) 0110112013 011012013 0110112013 0110112 114 01101/2014 01/0112014 X I WC STATU- OTH- EL. EACH ACCIDENT $ 2,000,000 P.L. DISEASE - EA EMPLOYEE $ 2,000,000 C dasondUe under If DESCRIPTION OF OPERATIONS balsa WC0es. 18112603 (CA) Dl/D112013 01/01/2914 E.L. DISEASE -POLICY LIMIT $ 2,000'000 B CRIME 015715287 01/01/2013 0110112014 LIMIT 10,000.000 $5Ml$15M DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more apace Is required) Branch Location: Adecco Engineenng 8 Technical, 300 E. Boardvvalk, Fort Collins, CO 80525. City of Fort Collins Attn: Ed. Bonnefte 215 N. Mason St. Fort Collins, CO 80522 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE of Marsh USA Inc. Jason Clarke 11988.20110 ACORD CORPORATION_ All rinhts rneerued ACORD 25 (2010105) The ACORD name and logo are registered marks of ACORD A� b® CERTIFICATE OF LIABILITY INSURANCE DATE OBI01/2013 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 Marsh USA, Inc. 1166 Avenue of the Americas New York, NY 10036 Attn: Adecco.Celts@marsh.win Fax: 212-948-0018 CONTACT NAME: PHONE FAX Alc No E-MAIL INSURERS AFFORDING COVERAGE NAIC M INSURERA: AXA Insurance Company 33022 370044-ALL-Mmte-13-14 NO INSURED Adewo Inc. INSURER B: NIA NIA INSURER C : Insurance Company Of The State Of PA 19429 175 Broad Hollow Road Melville, NY 11747-4902 INSURER D: New Hampshire Insurance Company 23841 INSURER E : INSURER F: COVERAGES CERTIFICATE NUMBER: NYC-006685058-01 RFVI.SIr]N NIIMRFR• t 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 LTR rypE OF INSURANCE ADOL UBR POLICY NUMBER POLICY EFF MMIDD/YYYY1 POLICY EXP IMMIDDIYY`YY1 LIMITS A GENERAL LIABILITY PCS002071(13) 08/01/2013 01/01/2014 EACH OCCURRENCE $ 2,000.000 X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE � OCCUR DAMAGE RENTED PREMISES Ea ccwrrence $ 2,000,OIb MED EXP (Any one person) $ N/A PERSONAL B ADV INJURY $ 2,000.000 GENERAL AGGREGATE $ 4,000,000 GENT AGGREGATE LIMIT APPLIES PER'. PRODUCTS - COMP/OP AGG $ 4,000,000 X I POLICY r X PRO- X LOC $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea accitlent - BODILY INJURY (Per person) $ ANY AUTO ALL OWNED SCHEDULED AUTOS AUTOS BODILY INJURY Per accident ( ) $ HIRED AUTOS NON OWNED AUTOS PROPERTY DAMAGE Peraccident $ $ UMBRELLA UAB OCCUR EACH OCCURRENCE $ AGGREGATE $ EXCESS LIAB CLAIMS -MADE DED RETENTION$ $ C WORKERS COMPENSATION WC018112601(AOS-30 STATES) 01/01/2013 01/0112014 OTH- D C C AND EMPLOYERS LIABILITY ANY PROPRIETORIPARTNER/EXECUTIVE YIN OFFICER/MEMBER EXCLUDED? N (Mandatory in NH) It DESCRIPTION OF OPERATIONS below N / A WC018112602 (AOSI2 STATES) WC018112605(MA,ND,WA,WI,WY) WC018112603 (CA) 01/01/2013 01/01/2013 01101/2013 01/0112014 01101/2014 01/01Y1014 MSMUT E.L. EACH ACCIDENT $ 2,000.000 EL. DISEASE - EA EMPLOYEE $ 2,000,000 E.L. DISEASE -POLICY LIMIT $ 2,000,000 DESCRIPTION OF OPERATIONS / LOCATIONS I VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required) Branch Location: Adecco Slaffing, 3711 JFK Parkway, Suite 305, Fort Collins, CO 80525, City of Fort Collins Arm: Ed Bwnette 215 N. Mason St. Fort Collins, CO 80524 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE of Marsh USA Inc. Jason Clarke — © 1988-2010 ACORD CORPORATION. All rights reserved ACORD 25 (2010105) The ACORD name and logo are registered marks of ACORD AGENCY CUSTOMER ID: 370044 LOC #: New York A � ADDITIONAL REMARKS SCHEDULE Page 2 of 2 AGENCY Marsh USA, Inc, NAMED INSURED Alecto Inc. 175 Broad Hollow Road Melville, NY 11747-4902 POLICY NUMBER CARRIER NAIC CODE EFFECTIVE DATE: THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, FORM NUMBER: 25 FORM TITLE: Certificate of Liability Insurance WORKERS COMP CONTINUED: INSURER: INSURANCE COMPANY OF THE STATE OF PA POLICY NUMBER: WC018112604 (FL) EFFECTIVE DATE'. 1/112013 EXPIRATION DATE: 111/2014 INSURER: ILLINOIS NATIONAL INSURANCE CO. POLICY NUMBER'. WC018112606 )MN) EFFECTIVE DATE: 11112013 EXPIRATION DATE: 111/2014 EXCESS WORKERS COMP: INSURER: ILLINOIS NATIONAL INSURANCE CO. POLICY NUMBER: WC6636171 (OH) EFFECTIVE DATE: 111R013 EXPIRATION DATE: 1112014 LIMITS: SIR. $3,000,000 EL EACH ACCIDENT: $1,000,000 EL DISEASE: $1,000,000 EL DISEASE - EACH EMPLOYEE: $1,000,000 ACORD 101 (2008/01) © 2008 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD Marsh USA Inc. 10900 Stonelaka Blvd, Austin, TX 78759 m .marsh.com L1_= To Whom It May Concern: The enclosed certificate of insurance supersedes any other certificate previously submitted to your office for the referenced coverages on behalf of the referenced Insured for the 2013/2014 policy period. The following three insurance policies previously referenced on certificates sent to your office have been replaced as following; General Liability — Policy Number - 9645242 National Union Fire Insurance Company of Pittsburgh has been replaced by - Policy Number PSC002071(13) AXA Insurance Company Umbrella Liability - Policy Number — US00045047LI13A XL Insurance America Inc has been replaced by - Policy Number XS002072(13) AXA Insurance Company Errors and Omission - Policy Number — 167112912 Continental Casualty Company has been replaced by - Policy Number PCS002073(13) AXA Insurance Company Please contact your Marsh Centralized Services Representative at Adecco.CertsCd)marsh.com if you have any questions regarding the attached Certificate of Insurance. Thank you Centralized Services Marsh USA Inc. AGENCY CUSTOMER ID: 370044 LOC #: New York ACOR" 166�" ADDITIONAL REMARKS SCHEDULE Page 2 of 2 AGENCY Marsh USA, Inc. NAMED INSURED Adecco Inc. 175 Broad Hollow Road Melville, NY 117474902 POLICY NUMBER CARRIER NAIC CODE EFFECTIVE DATE: THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, FORM NUMBER: 25 FORM TITLE: Certificate of Liability Insurance WORKERS COMP CONTINUED: INSURER: INSURANCE COMPANY OF THE STATE OF PA POLICY NUMBER: WC018112604 (FL) EFFECTIVE DATE: 1/112013 EXPIRATION DATE: 1/12014 INSURER'. ILLINOIS NATIONAL INSURANCE CO. POLICY NUMBER: WC018112606 (MN) EFFECTIVE DATE. 1/112013 EXPIRATION DATE: 1/12014 EXCESS WORKERS COMP: INSURER: ILLINOIS NATIONAL INSURANCE CO. POLICY NUMBER: WC6636171 (OH) EFFECTIVE DATE: 1/1/2013 EXPIRATION DATE: 1/1/2014 LIMITS: SIR. $3,000,000 EL EACH ACCIDENT: $1,000,000 EL DISEASE: $1,000,000 EL DISEASE - EACH EMPLOYEE: $1,000,000 ACORD 101 © 2008 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD Marsh USA Inc. 10900 Stonelake Blvd. Austin, TX 78759 w marsh.com 1 hi i-i 1 tad To Whom It May Concern: The enclosed certificate of insurance supersedes any other certificate previously submitted to your office for the referenced coverages on behalf of the referenced Insured for the 2013/2014 policy period. The following three insurance policies previously referenced on certificates sent to your office have been replaced as following; General Liability — Policy Number - 9645242 National Union Fire Insurance Company of Pittsburgh has been replaced by - Policy Number PSC002071(13) AXA Insurance Company Umbrella Liability - Policy Number — US00045047LI13A XL Insurance America Inc has been replaced by - Policy Number XS002072(13) AXA Insurance Company Errors and Omission - Policy Number — 167112912 Continental Casualty Company has been replaced by - Policy Number PCS002073(13) AXA Insurance Company Please contact your Marsh Centralized Services Representative at Adecco.CertsOrnarsh.com if you have any questions regarding the attached Certificate of Insurance. Thank you Centralized Services Marsh USA Inc. A� b® CERTIFICATE OF LIABILITY INSURANCE OATE(MMn30YYVV) OBI01/2013 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 Marsh USA, Inc. 1166 Avenue of the Americas New York, NY 10036 Attn: Adeccu.Certs@marsh.win Fax: 212-948-0018 CONTACT NAME: PNONE FAX ExUAC No: nooaless: INSURERS AFFORDING COVERAGE NAIC k INSURER A: AXA Insurance Company 33022 370044-ALL-Maste-13-14 NO INSURED o Inc. Adec175 INSURER B : National Union Fire Insurance Cc Of Pittsburgh 19445 Insurance Company Of The State Of PA INSURER C : � Y 19429 ' B 175 Broad Hollow Road Melville, NY 11747-4902 INSURER D : New Hampshire Insurance Company 23841 INSURER E : INSURER F: COVERAGES CERTIFICATE NUMBER: NYC-f10GfillSfA nl RFVIRInm NI IMRFG•1 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 LTR TYPE OF INSURANCE ADDL UBR POLICY NUMBER POLICY EFF MMIDOIYYYY POLICY EXP MMIDDIYYYY LIMITS A GENERAL LIABILITY PCS002071(13) OBIOWO13 01101 014 EACH OCCURRENCE $ 2,000,000 X COMMERCIAL GENERAL LIABILITY CLAIMS-MADE M OCCUR PREMISES[MMAGante 20 $ ,(10400 NED EXP(Any one person) $ NIA PERSONAL B ADV INJURY $ 2,000,000 GENERAL AGGREGATE $ 4.000,000 GEN'L AGGREGATE LIMIT APPLIES PER PRODUCTS - COMPIOP AGG $ 4,000,000 X POLICY FX PRO- X LOC $ B B AUTOMOBILE LIABILITY ANY AUTO CA 5196216 (AOS) CA 5196218(MA) 01/01/2013 0110112013 01101/2014 01/01/2014 COMBINED SINGLE LIMIT (Ea accident 2,000,000 X BODILY INJURY (Per parson) $ ALL OS SCHEDULED AUTOS AUTOS BODILY INJURY Per accident ( ) $ HIRED AUTOS NON -OWNED AUTOS PROPERTY DAMAGE Per -accident $ A X UMBRELLA LIAB X OCCUR XS002072(13) 08JO112013 0110112014 EACH OCCURRENCE $ 5,000,000 AGGREGATE $ 5,000,000 EXCESS LIAB CLAIMS MADE DED X RETENTIONS 10,000 $ C D C C WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANY PROPRIETORIPARTNERIEXECUTIVE YIN OFFICER/MEMBER EXCLUDED9 ❑N (Mandatory in NH) If : dasvitoe under DESCRIPTION OF OPERATIONS bebw N/A WC018112601(AOS30STATES) WCA18112602 (A05-12 STATES) WC018112605(MA,NRWA,WI,WY) WC018112603 CA ( ) 01/0112013 0110112013 01/0112013 0110112013 01/01/2014 01I0112014 0110112014 01101/2014 X SSTATU- OTH- E.L. EACH ACCIDENT $ 2,000,000 E. L. DISEASE - EA EMPLOYEE $ 2,000,000 E.L. DISEASE - POLICY LIMIT 1 $ 2,000,000 DESCRIPTION OF OPERATIONS / LOCATIONS I VEHICLES (Attach ACORD 101, Additional Ramarut Schedule, If more space is required) Branch Location: Adecco Engineenng 8 Technical, 4025 Automation Way F1, Fort Collins, CO 80525. City of Fort Collins Attn: Ed Bonnette 215 N. Mason St, Fat Collins, CO 80522 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE of Marsh USA Inc. Jason Clarke —3 fye­14==Z_ © 1988.2010 ACORD CORPORATION. All rights reuerved ACORD 25 (2010105) The ACORD name and logo are registered marks of ACORD AGENCY CUSTOMER ID: 370044 LOC #: New York A ADDITIONAL REMARKS SCHEDULE Page 2 of 2 AGENCY Marsh USA, Inc. NAMED INSURED Adecco Inc. 175 Broad Hollow Road Melville, NY 11747A902 POLICY NUMBER CARRIER NAIC CODE EFFECTIVE DATE: THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, FORM NUMBER: 25 FORM TITLE: Certificate of Liability Insurance WORKERS COMP CONTINUED: INSURER: INSURANCE COMPANY OF THE STATE OF PA POLICY NUMBER'. WC018112604 (FL) EFFECTIVE DATE: 111/2013 EXPIRATION DATE: 111/2014 INSURER: ILLINOIS NATIONAL INSURANCE CO. POLICY NUMBER: WC018112606 (MN) EFFECTIVE DATE: 1/1/2013 EXPIRATION DATE: 111/2014 EXCESS WORKERS COMP: INSURER'. ILLINOIS NATIONAL INSURANCE CO. POLICY NUMBER: WC6636171 (OH) EFFECTIVE DATE'. 1/1/2013 EXPIRATION DATE'. 1/1/2014 LIMITS'. SIR: $3,000,000 EL EACH ACCIDENT: $1,000,000 EL DISEASE: $1,000,000 EL DISEASE - EACH EMPLOYEE: $1,000,000 AUUKU 7U7 (ZUUE/U7) © 2008 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD Marsh USA Inc. 10900 Stonelake Blvd. Austin, TX 78759 w .marsh corn Memo To Whom It May Concern: The enclosed certificate of insurance supersedes any other certificate previously submitted to your office for the referenced coverages on behalf of the referenced Insured for the 2013/2014 policy period. The following three insurance policies previously referenced on certificates sent to your office have been replaced as following; General Liability — Policy Number - 9645242 National Union Fire Insurance Company of Pittsburgh has been replaced by - Policy Number PSC002071(13) AXA Insurance Company Umbrella Liability - Policy Number — US00045047LI13A XL Insurance America Inc has been replaced by - Policy Number XS002072(13) AXA Insurance Company Errors and Omission - Policy Number — 167112912 Continental Casualty Company has been replaced by - Policy Number PCS002073(13) AXA Insurance Company Please contact your Marsh Centralized Services Representative at Adecco.Certs(a)marsh.com if you have any questions regarding the attached Certificate of Insurance. Thank you Centralized Services Marsh USA Inc. '``I �® CERTIFICATE OF LIABILITY INSURANCE DATE(MMIODYYYY) 0810112MM 013 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 CONTACT NAME: Marsh USA, Inc. PHONE F�AXC 1166Avenueofthe Americas No: E MAIL Nev, York, NY 10036 Attn: Adecco.Certs@marsh.com I Fax: 212-948-0018 ss: INSURERS AFFORDING COVERAGE NAIC Y INSURER A: AXA Insurance Company 33022 370044-ALL-Maste-13-14 NO INSURED AdecINSURER o Inc. B : NIA NIA INSURER C: Insurance Company Of The State Of PA 19429 175 Broad Hollow Road 7$ Melville, NY 11747A902 INSURER D: New Hampshire Insurance Company 23841 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: NYC-006685059.01 RFVISION NI IMRFR• 1 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, EXCLUSIONSAND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR LTR TYPE OF INSURANCE ADDL INSR USR POLICY NUMBER POLICY EFF IMMIDDMYYI POLICY EXP LIMITS A GENERALUABILITY PCS002071(13) 08101/2013 _LMMIDOMWI 01/01/2014 EACH OCCURRENCE $ 2,000,000 X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE O OCCUR DAMAGERENTED PREMISESS ( Ea occurrence) $ 2,000,000 MED EXP (Any we person) $ N/A PERSONAL 8 ADV INJURY $ 2.000,000 GENERAL AGGREGATE $ 4,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 4,000,000 X POLICY X PRO- M LOC $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea accident BODILY INJURY (Per person) $ ANY AUTO ALL OWNED SCHEDULED AUTOS AUTOS BOPer accident ( ) $ HIRED AUTOS NON -OWNED AUTOS MAGE $ UMBRELLA LUIB OCCUR ENCE $ Ld !AGGaREGATE $ EXCESS LIAR CLAIMS -MADE DED RETENTION$ $ C WORKERS COMPENSATION WC018112601 (AOS30 STATES) 01/01/2013 01101I2014 U- OTH- D C C AND EMPLOYERS' LIABILITYER ANY PROPRIETOR/PARTNER/EXECUTIVE YIN OFFICER/MEMBER EXCLUDED? E (Mandatory in NH) describs, under.L. (DESCRIPTION OF OPERATIONS below NIA WC018142602(AOSI2 STATES) WC018112605(MA,ND,WA,W(WY) WC018112603 (CA) 01/01/2013 0110112013 01/0112013 01I01I2014 01/01/2014 01/01/2014 E.L. EACH ACCIDENT $ 2,000,000 DISEASE -EA EMPLOYE Ees, $ 2,000,000 E.L. DISEASE -POLICY LIMIT $ 2,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101, Additional Remarks Schedule, It more space Is required) Branch Location Adecco Engineering 8 Technical, 300 E. Boardwalk, Fort Collins, CO 80525. City of Fort Collins Attn: Ed Bonnette 215 N. Mason St. Fort Collins, CO 80524 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE of Marsh USA Inc. Jason Clarke -3 4fy4-14=2._ ©1988-2010 ACORD CORPORATION- All rinhtR raenrvnd ACORD 25 (2010/05) The ACORD name and logo are registered marks of ACORD AGENCY CUSTOMER ID: 370044 LOC III: New York A` oRo® ADDITIONAL REMARKS SCHEDULE Page 2 of 2 AGENCY Marsh USA, Inc. NAMED INSURED Adecm Inc. 175 Broad Hollow Road Meldlle, NY 11747-4902 POLICY NUMBER CARRIER NAIC CODE EFFECTIVE DATE: ADDITIONAL REMARKS THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, FORM NUMBER: 25 FORM TITLE: Certificate of Liability Insurance WORKERS COMP CONTINUED: INSURER'. INSURANCE COMPANY OF THE STATE OF PA POLICY NUMBER: WC018112604 (FL) EFFECTIVE DATE: V112013 EXPIRATION DATE: 111/2014 INSURER: ILLINOIS NATIONAL INSURANCE CO. POLICY NUMBER: WC018112506 (MN) EFFECTIVE DATE: 11412013 EXPIRATION DATE: 1112014 EXCESS WORKERS COMP: INSURER. ILLINOIS NATIONAL INSURANCE CO. POLICY NUMBER'. WC6636171 (OH) EFFECTIVE DATE: 1/112013 EXPIRATION DATE: 11112014 LIMITS: SIR:$3,000,000 EL EACH ACCIDENT: $1,000,000 EL DISEASE: $1,000,000 EL DISEASE - EACH EMPLOYEE: $1,000,000 ACORD 101 (2008101) © 2008 ACORD CORPORATION. All riehts reserved. The ACORD name and logo are registered marks of ACORD Marsh USA Inc. 10900 Stonelaka Blvd, Austin, TX 75759 �, mwsh,com Memo To Whom It May Concern: The enclosed certificate of insurance supersedes any other certificate previously submitted to your office for the referenced coverages on behalf of the referenced Insured for the 2013/2014 policy period. The following three insurance policies previously referenced on certificates sent to your office have been replaced as following; General Liability — Policy Number - 9645242 National Union Fire Insurance Company of Pittsburgh has been replaced by - Policy Number PSC002071(13) AXA Insurance Company Umbrella Liability - Policy Number — US00045047LI13A XL Insurance America Inc has been replaced by - Policy Number XS002072(13) AXA Insurance Company Errors and Omission - Policy Number — 167112912 Continental Casualty Company has been replaced by - Policy Number PCS002073(13) AXA Insurance Company Please contact your Marsh Centralized Services Representative at Adecco.Certs( marsh.com if you have any questions regarding the attached Certificate of Insurance. Thank you Centralized Services Marsh USA Inc.