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HomeMy WebLinkAbout114084 EXPRESS SERVICES INC - INSURANCE CERTIFICATEANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? INSR ADDL SUBR LTR INSR WVD DATE (MM/DD/YYYY) PRODUCER CONTACT NAME: PHONE FAX (A/C, No, Ext): (A/C, No): E-MAIL ADDRESS: INSURER A : INSURED INSURER B : INSURER C : INSURER D : INSURER E : INSURER F : POLICY NUMBER POLICY EFF POLICY EXP TYPE OF INSURANCE (MM/DD/YYYY) (MM/DD/YYYY) LIMITS GENERAL LIABILITY AUTOMOBILE LIABILITY UMBRELLA LIAB EXCESS LIAB WORKERS COMPENSATION AND EMPLOYERS' LIABILITY DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required) AUTHORIZED REPRESENTATIVE EACH OCCURRENCE $ DAMAGE TO RENTED COMMERCIAL GENERAL LIABILITY PREMISES (Ea occurrence) $ CLAIMS-MADE OCCUR MED EXP (Any one person) $ PERSONAL & ADV INJURY $ GENERAL AGGREGATE $ GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP/OP AGG $ PRO- $ POLICY JECT LOC COMBINED SINGLE LIMIT (Ea accident) $ ANY AUTO BODILY INJURY (Per person) $ ALL OWNED SCHEDULED BODILY INJURY (Per accident) $ AUTOS AUTOS HIRED AUTOS NON-OWNED PROPERTY DAMAGE $ AUTOS (Per accident) $ OCCUR EACH OCCURRENCE $ CLAIMS-MADE AGGREGATE $ DED RETENTION $ $ WC STATU- OTH- TORY LIMITS ER E.L. EACH ACCIDENT $ E.L. DISEASE - EA EMPLOYEE $ If yes, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT $ INSURER(S) AFFORDING COVERAGE NAIC # Y / N N / A (Mandatory in NH) SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Express Services, Inc. Workers Compensation Policy Schedule: Policy periods: 10/1/13-14 The Insurance Company of the State of Pennsylvania Policy No. WC015630781 NAIC# 19429 States Covered: CA Illinois National Insurance Co. Policy No. WC015630782 NAIC# 23817 States Covered: ME Illinois National Insurance Co. Policy No. WC015630789 NAIC# 23817 States Covered: FL National Union Fire Insurance Company of Pittsburgh, PA Policy No. WC015630783 NAIC# 19445 States Covered: MA, ND, WI, WY National Union Fire Insurance Company of Pittsburgh, PA Policy No. WC6636228 NAIC# 19445 States Covered: OH National Union Fire Insurance Company of Pittsburgh, PA Policy No. WC6636229 NAIC# 19445 States Covered: WA New Hampshire Insurance Company Policy No. WC015630784 NAIC# 23841 States Covered: AR, CO, DC, DE, HI, ID, MS, MT, NM, NV, OK, RI, SD, TN, TX, WV New Hampshire Insurance Company Policy No. WC015630785 NAIC# 23841 States Covered: IL, KY, NC, NH, UT, VT New Hampshire Insurance Company Policy No. WC015630786 NAIC# 23841 States Covered: NJ, PA New Hampshire Insurance Company Policy No. WC015630787 NAIC# 23841 States Covered: AK, AZ, GA, VA New Hampshire Insurance Company Policy No. WC015630788 NAIC# 23841 States Covered: AL, CT, IA, IN, KS, LA, MD, MI, MN, MO, NE, NY, OR, SC Miscellaneous Attachment: M480401 Master ID: 1352730, Certificate ID: 11957536 THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. 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. 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). COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: CERTIFICATE HOLDER CANCELLATION © 1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25 (2010/05) The ACORD name and logo are registered marks of ACORD CERTIFICATE OF LIABILITY INSURANCE Lockton Companies, LLC-1 Kansas City 444 W. 47th Street, Suite 900 Kansas City MO 64112-1906 (816) 960-9000 EXPRESS SERVICES, INC. DBA: EXPRESS EMPLOYMENT PROFESSIONALS 8516 NW EXPRESSWAY OKLAHOMA CITY, OK 73162 EXPSE01 American Guarantee and Liab. Ins. Co. 26247 New Hampshire Insurance Company 23841 Zurich American Insurance Company 16535 X X X STAFFING SERVICE 5,000,000 1,000,000 10,000 5,000,000 5,000,000 5,000,000 X X 1,000,000 XXXXXXX XXXXXXX XXXXXXX XXXXXXX X X 20,000,000 20,000,000 XXXXXXX N X 1,000,000 1,000,000 1,000,000 CRIME/FIDELITY STAFFING E&O COVERAGE CRIME/FIDELITY: 5,000,000 E&O OCC/AGG: 5,000,000 B PRA5854213-01 10/1/2013 10/1/2014 B PRA5854213-01 10/1/2013 10/1/2014 B PRA5854213-01 10/1/2013 10/1/2014 C UMB5498877-01 10/1/2013 10/1/2014 A SEE ATTACHED POLICY #'S 10/1/2013 10/1/2014 10/1/2014 1352730 Y N Y N Y N N 9/24/2013 N N 11957536 11957536 XXXXXXX CITY OF FORT COLLINS ATTN: JAMES B. O'NEILL 215 NORTH MASON STREET FORT COLLINS CO 80521 ALL INSURANCE CARRIERS SHOWN ON THIS CERTIFICATE HAVE AN A.M. BEST RATING OF A XV OR BETTER UNLESS OTHERWISE NOTED. LOCATION: 1016 - FORT COLLINS, CO / TYPE OF COMPANY: MUNICIPALITY / JOB DESCRIPTION: GENERAL CLERICAL AND ADMINISTRATIVE SUPPORT POSITIONS / CITY OF FORT COLLINS IS LISTED AS AN ADDITIONAL INSURED AS RESPECTS TO WORK PERFORMED BY TEMPORARY ASSOCIATES, AS PER WRITTEN CONTRACT AND/OR STAFFING AGREEMENT, EXCEPT FOR NEGLIGENCE OR WILLFUL MISCONDUCT OF CITY OF FORT COLLINS. ADDITIONAL INSURED DOES NOT APPLY TO WC, E&O OR FIDELITY. X ACORD 25 (2010/05) The ACORD name and logo are registered marks of ACORD ©1988-2010 ACORD CORPORATION. All rights reserved See Attachment