HomeMy WebLinkAbout127666 MICHAEL TRUCKING - INSURANCE CERTIFICATE (18)A�i p® CERTIFICATE OF LIABILITY INSURANCE
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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
Gary Cramer, Agent
CONTACT
NAME: Gary Cramer
4.PHONE 1 74 FACC No:970A93-0226
State Farm Insurance
StareFamr 1275 E Magnolia Unit I
�s Fort Collins, CO 80525
n'o"oalEss: a .cramer.b68o slaleform.com
INSURERS AFFORDING COVERAGE
NAIL
INSURER A: State Farm Fire and Casualty Company
INSURED MICHAEL, DWGHTJ
INSURER B:
INSURERC:
DSA MICHAEL TRUCKING
INSURER D:
2450 W ELIZABETH ST
FORTCOLLINSCO 80521-4120
INSURER E:
NSURER F:
COVFRAf FS CFRTIFICATF NUMBER- REVISION NUMBER:
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
TRIN9R
TYPE OF INSURANCE
A DLSi
MO
pOUCY NUMBER
MMA)DPOLICYEFF
MPpY WPY
UNITS
GENERALUABIUTY
Y
❑
EACH OCCURRENCE
3 1,000,0Do
PREMISes EOEs��nence
E 300,000
COMMERCIAL GENERAL LIABILITY
96-BVJ768-2
0211912013
0211912014
MED EXP (Anyone pmw)
s 5,000
CLAIMSHAADE ❑ OCCUR
PERSONAL 8 ADV INJURY
S 1,DD0,000
BUSINESS
GENERAL AGGREGATE
S 2,000,000
GEN'L AGGREGATE LIMIT APPLIES PER
PRODUCTS -COMPIOP AGG
S 2,000.000
E
POLICY I I PRO LOC
AUTOMOBILE LIABILITY
Y
_
E MB-_INE_I IN LI IT
S
EDGILY INJURY (Per pers )
E 50D,000
ANY AUTO)11F
2793128-C18-08A-001
09JIS12013
0311IU2013
BODILY INJURY(Per amlderd)
E 5G0,0GG
ALL AUTOS AUTOSUL�
PROPERTY DAMAGE
Perecddmi
E 500,00G
NON -OWNED
HIRED AUTOSAUTOS
P
E
UMBRELLA LUIB
OCCUR
EACH OCCURRENCE
$
AGGREGATE
E
EXCESS UAB
CLAIMS -MADE
DIED I I RETENTIONS
E
WORXERSCOMPENSATION
AND EMPLOYERS' LIABILITY Y r N
ANY PROPRIETORMARTNER/FXECUTTVE
'
WC STAM U- OTH-
I YE
E.L. EACH ACCIDENT
$
OFFICENEMBER EXCLUDED? ❑
NIA
❑
E.L. DISEASE: EA EMPLOYEE
S
(Mandatdiy In Ni
E.L. DISEASE -POLICY LIMIT
S
If M. desmLe underDESCRIPTION OF OPERATIONqbe�m
DESCRIPTIONOFOPERATIONSILOCAnONS/VEHICLES (Attach ACORD101.Add otl lRemaM&Sched a,Nmom.Wcaleraavbadl
1997 INTERNATIONAL 4900, MN 1 HTSHADR5VH473601.
The insurance evidenced by this Certificate will not be cancelled or materially altered, except after ten (10) days written noticehas been received by the City of
Fort Collins.
NOTICE OF INTENT TO CANCEL OR MATERIALLY ALTER IS TO BE PROVIDED BY THE POLICYHOLDER TO THE CITY OF FORT COLLINS.
Notice of cancellation will be provided by State Farm Fire and Casualty Company.
CITY OF FORT COLLINS
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.
AUTNV�ATTVE
TION. All rinbfR ranarved_
ACORD 26 (2010105) The ACORD name and logo are registered marks of ACORD 1001486 132949.8 01-23-2013
