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HomeMy WebLinkAboutEVANS TRUCKING LLC - INSURANCE CERTIFICATE (3)05-31-3535839-2 Shelter Mutual Insurance Company ***MANUAL DEC*** 1817 W Broadway Columbia, MO 65218 1-800-SHELTER (743-5837) R General Liability Insurance Policy Declarations Named Insured: *BRUCE R EVANS T'1v vV�i �� �—� • Policy Number: 05-31-3535839-2 6490 N COUNTY ROAD 3 Effective Date: 07/29/2013 (12:01 A.M. CST) FORT COLLINS CO 80524-9304 Expiration Date: 08/29/2013 (12:01 A.M. CST) Agent: BRUCE JOHNSON AGENCY INC 05-5549-10 PO BOX 270663 FORT COLLINS CO 80527 970-226-5034 Notice to the Mortgagee/Loss Payee/Addl Insured: Your interest will be continuous until cancellation notice is mailed to you. Business of the Named Insured: HAULS DIRT/ROCK The Named Insured is a(n): \ Audit Period: a.,� .- LLnnllt, 011n5nran99.2-- $ice•,;, .a ? a r ,.x' .? -. ,;,"}°..` General Aggregate (Other Than Products — Completed Operations) $2,000,000 Products — Completed Operations Aggregate Limit (See Each Classification Below) Included Personal And Advertising Injury Limit $1,000,000 Each Occurrence Limit $1,000,000 Rented To You Limit $100,000 Medical Expense Limit $5,000 Individual Annually Any One Premises Any One Person PREMISES & OPERATIONS- 99793 TRUCKERS PAYROLL PER $1000 6.674 $168.00 INCLUDING PRODUCTS &/OR COMPLETED OPERATIONS $25,200 ITEM ZIP CODE: 80524 PREMISES & OPERATIONS- 88801 PREMIUM CHARGE FOR REINSURANCE OF $500,000 $938.00 OCCURRENCE, EXCESS OF $500,000 OCCURRENCE. ITEM ZIP CODE: 80524 6490 N COUNTY ROAD 3 FORT COLLINS CO Additional Insured - Owners, Lessees or Contractors - CG 20 10 04 13 $17.00 Scheduled Person or Organization BIVENS TRUCKING AND EXCAVATING Total for Term (This is Not a Bill): $1,174.00 Pohcy forms and.additioaal endorsemei►tsattached to this p licp },#„N tuber Y Commercial General Liability Coverage Form CG 00 0104 13 Excl Damage To Work By Subcontr On Your Behalf CG 22 94 10 01 Fungi Or Bacteria Exclusion CG 2167 12 04 Total Pollution Exclusion Endorsement CG 2149 09 99 Exclusion - Exterior Insulation And Finish Systems CG 21 86 12 04 Exclusion - Year 2000 Computer -Related & Electronic Problems CG 2160 09 98 ce Page 1 05-31-3535839-2 Mutual Policy Notification 5-18-S Amendatory Endorsement (Pollution Exclusion) G-252-G Non -Binding Arbitration CG 24 01 12 04 Employment -Related Practices Exclusion CG 21 47 12 07 Lead Poisoning Exclusion Endorsement B-601-B Asbestos Exclusion B-559-B Colorado Changes - Cancellation And Nonrenewal H, 02 28 09 07 Nuclear Energy Liability Exclusion Endorsement (Broad Form) 11- 00 2105 02 Limitation Of Coverage To Designated Premises Or Projects Described Premises CG 21 44 07 98 Common Policy Conditions IL 00 17 1198 MARTIN MARIETTA MATERIALS 2710 WYCLIFF RD RALEIGH NC 27607-3033 Addl=Insured P, �< •_, CITY OF FORT COLLINS PO BOX 580 FORT COLLINS CO 80522-0580 (For Office Use Only) Transaction: P.C. H. O. CODE: 1,174.00 Policy ID: 66004218766 Policy Term: One Year Date Issued: 07-29-2013 '03082013' Addl'Insured'^4.' ' BIVENS TRUCKING AND EXCAVATING 862 W WILLOX LN FORT COLLINS CO 80524-1147 CONNELL RESOURCES INC 5150 SE FRONTAGE RD FORT COLLINS CO 80528-9526 G-2.10-G ~ 3r x End ofyD.eClarations. ce Page 2 05-31-3535839-2 Shelter Mutual Insurance Company ***MANUAL DEC*** 1817 W Broadway Columbia, MO 65218 1-800-SHELTER (743-5837) A General Liability Insurance Policy Declarations Named Insured: BRUCE R EVANS Policy Number: 05-31-3535839-2 6490 N COUNTY ROAD 3 Effective Date: 08/29/2013 (12:01 A.M. CST) FORT COLLINS CO 80524-9304 Expiration Date: 08/29/2014 (12:01 A.M. CST) Agent: BRUCE JOHNSON AGENCY INC 05-5549-10 PO BOX 270663 FORT COLLINS CO 80527 970-226-5034 Notice to the Mortgagee/Loss Payee/Addl Insured: Your interest will be continuous until cancellation notice is mailed to you. Business of the Named Insured: HAULS DIRT/ROCK The Named Insured is a(n): Individual Audit Period: Annually Croats of Insurance' General Aggregate (Other Than Products — Completed Operations) $2,000,000 Products — Completed Operations Aggregate Limit (See Each Classification Below) Included Personal And Advertising Injury Limit $1,000,000 Each Occurrence Limit $1,000,000 Rented To You Limit $100,000 Any One Premises Medical Expense Limit $5,000 Any One Person PREMISES & OPERATIONS- 99793 TRUCKERS PAYROLL PER.$1000 6.674 $168.00 INCLUDING PRODUCTS &/OR COMPLETED OPERATIONS $25,200 ITEM ZIP CODE: 80524 PREMISES & OPERATIONS- 88801 PREMIUM CHARGE FOR REINSURANCE OF $500,000 $938.00 OCCURRENCE, EXCESS OF $500,000 OCCURRENCE. ITEM ZIP CODE: 80524 6490 N COUNTY ROAD 3 FORT COLLINS CO Additional Insured - Owners, Lessees or Contractors - CG 20 10 04 13 $17.00 Scheduled Person or Organization BIVENS TRUCKING AND EXCAVATING Total for Term (This is Not a Bill): $ l ,174.00 rPohcy forms and additional endorsements attached to thts poLcy� .� x - � Number u Commercial General Liability Coverage Form CG 00 01 04 13 Excl Damage To Work By Subcontr On Your Behalf CG 22 94 10 01 Fungi Or Bacteria Exclusion CG 21 67 12 04 Total Pollution Exclusion Endorsement CG 21 49 09 99 Exclusion - Exterior Insulation And Finish Systems CG 21 86 12 04 Exclusion - Year 2000 Computer -Related & Electronic Problems CG 2160 09 98 ce Page l 05-31-3535839-2 Mutual Policy Notification S-18-S Amendatory Endorsement (Pollution Exclusion) G-252-G Non -Binding Arbitration CG 24 01 12 04 Employment -Related Practices Exclusion CG 21 47 12 07 Lead Poisoning Exclusion Endorsement B-601-B Asbestos Exclusion B-559-B Colorado Changes - Cancellation And Nonrenewal IL 02 28 09 07 Nuclear Energy Liability Exclusion Endorsement (Broad Form) IL 00 21 05 02 Limitation Of Coverage To Designated Premises Or Projects Described Premises CG 2144 07 98 Common Policy Conditions IL 00 17 11 98 AddleInsured MARTIN MARIETTA MATERIALS 2710 WYCLIFF RD RALEIGH NC 27607-3033 AddlInsured = CITY OF FORT COLLINS PO BOX 580 FORT COLLINS CO 80522-0580 (For Office Use Only) Transaction: RNEW B H. O. CODE: 1,174.00 Policy ID: 66004218766 Policy Term: One Year Date Issued: 07-29-2013 '07292013' Add1 Insured . "�` ` BIVENS TRUCKING AND EXCAVATING 862 W WILLOX LN FORT COLLINS CO 80524-1147 AddlInsured CONNELL RESOURCES INC 5150 SE FRONTAGE RD FORT COLLINS CO 80528-9526 G-2.10-G End of Declararions ce Page 2