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Home My WebLink AboutCORRESPONDENCE - BID - 7355 HAULING SERVICESr- April 8, 2013 Viney Trucking Inc Attn: Kevin Viney PO Box 1446 LaPorte, CO 80535 RE: 7355 Hauling Services 2012 Dear Mr. Viney: Financial Services Purchasing Divislon 215 N. Mason St. 2' Floor PO Box 580 Fort Collins, CO 80522 970.221.6775 970.221.6707- fax fcgov.coWpurchasing APR 17 2013 The City of Fort Collins wishes to extend the agreement term for the above captioned proposal per the existing terms and conditions. The term will be extended for one (1) additional year, April 1, 2013 through March 31, 2014. If the renewal is acceptable to your firm, please sign this letter in the space provided include a current copy of insurance naming the City as an additional insured and return all documents to the City of Fort Collins, Purchasing Division, P. O. Box 580, Fort Collins, CO 80522, within the next fifteen days. If this extension is not agreeable with your firm, we ask that you send us a written notice stating that you do not wish to renew the contract and state the reason for non -renewal. Please contact John Stephen, CPPO, LEED AP, Senior Buyer at (970) 221-6777 if you have any questions regarding this matter. Sincerly, John D. Stephen, CPPO, LEED AP Interim Director of Purchasing and Risk Management Z' I z�3 Signature Date (Please indicate your desire to renew 7355 by signing this letter and returning it to Purchasing Division within the next fifteen days.) A APR-25-2013 12:05 OCCUPATIONAL HEALTH 970 297 6699 P.006 Employer Account FL Collins Market Employorhisma; VimyTrucRing (CCM) Phone! (070) 4WI403. Phys Addroay. 2607 Broolchilf Rd Mail Address: 2807 OfookbIll Rd City. State, Fort Collin. CO A05241016 City, State, ZIP: POK Cobm. CO 006241013 ServicePadcligs- Injury Care Employer Admin No," 111BILUECHARrIll All Releffals to therapy REQUIRE AUTHORIZATION from Pinnawl Prior to the 12th V164, Pad Dispense made from our pharmacy preferred. If non4ormulary medo neQuIred, then wlta Rx and duach to the EXPRESS SCRIPTS form (located stlFrant desk). 00 NOT use occuecrIpt-P X( somparuint; Injury Coro 8t11 To: WIC Insurance Carrier Pifln000l Assurance Phone (600)973.7242 Fax (303),"1-51)(10 Page 4 o14 1906-MSCOWIA01,01M COW. MR*wRllllft L2:02 $0.00 AA/EEO Employer I PrIntDate: 04r25t2013 Reftlon Ottv 07126012 96% P-006 TnTAT. P nnp a STATE FARM INSURANCE COMPANIES® 1555 Promontory Circle Greeley 00 80636.0001 DATE OF NOTICE: MAY 16 2013 CODE: 33380 9A AT1 20 001072 0093 CITY OF FORT COLLINS FINANCIAL SERVICES PURCHASING DIVISION PO BOX 580 FORT COLLINS CO 80522-0580 NOTE: PLEASE NOTIFY STATE FARM AT THE ADDRESS LISTED AT THE TOP, LEFT CORNER OF THIS PAGE REGARDING ANY CHANGE OF ADDRESS INFORMATION. ADDITIONAL INSURED'S:<WTICE::OF COVERAGE'. .... ......... State Farm Mutual Automobile Insurance Company 2157-FAFl-G NAMED INSURED: POLICY NO: 057 1122-El7-06N -CAR 013 COVERAGE: o VINEY TRUCKING INC YR/MAKE/MODEL: 1997 PETERBILT TRACTOR BI AND PD LIABILITY N PO BOX 1446 VIN/CAMPER: 1XP5DB8X2VD433065 $ 2 MIL $1000 DED. COMP. LAPORTE CO 80535-1446 AGENT NAME: DARYL ALEXANDER INS AGCY INC $1000 DED. COLL. > AGENT PHONE: (970)493.2196 ¢ ENDORSEMENT NO: 6028BT POLICY EFFECTIVE m MAY 17 2013 UNTIL TERMINATED POLICY MESSAGES: This policy shown above supersedes policy# 0571122-06M. The policy includes a loss payable clause protecting the additional insured's interest in the described oar to the e:dent of the insurance n provided and subject to all policy provisions. The additional insured will be given 10 days notice if the policy is terminated. Until such notice uS is provided, it shall be presumed that the required renewal premiums have been paid. The additional insured must notify us within 10 days of any change of interest or ownership coming to their attention. Failure to do so will render this policy null and void. 0 p `ADDITIONAL INSURED'S NOTICE:OF.COVERAGE' State Farm Mutual Automobile Insurance Company 2157-FAFl-G NAMED INSURED: POLICY NO: 0571122-E17-06N CAR 023 COVERAGE: VINEY TRUCKING INC YR/MAKE/MODEL: 1994 PETERBILT TRACTOR BI AND PD LIABILITY PO BOX 1446 VIN/CAMPER: 1XP.5DR9X7RD347733 $ 2 MIL LAPORTE CO 80535-1446 AGENT NAME: DARYL ALEXANDER INS AGCY INC $1000 DED. COMP. $1000 DED. COLL. AGENT PHONE: (970)493-2196 ENDORSEMENT.NO: 6028BT , .'_ _.. POLICY EFFECTIVE, . MAY 17 2013 UNTIL TERMINATED POLICY MESSAGES: This policy shown above supersedes policy# 0571122-06M. The policy includes a loss payable clause protecting the additional insured's interest in the described oar to the e:dent of the insurance provided and subject to all policy provisions. The additional insured will be given 10 days notice if the policy is terminated. Until such notice is provided, it shall be presumed that the required renewal premiums have been paid. The additional insured must notify us within 10 days of v any change of interest or ownership coming to their attention. Failure to do so will render this policy null and void. 0 rt ADDITIONAL INSURED'S:,NOTICE OF COVERAGE:: State Farm Mutual Automobile Insurance Company 2157-FAFl-G NAMED INSURED: POLICY NO: 0571122-E17.06N CAR 033 COVERAGE: VINEY TRUCKING INC YR/MAKE/MODEL: 1996 PETERBILT TRACTOR el AND PD LIABILITY PO BOX 1446 VIN/CAMPER: 1XPFDB9X4TD398321 $ 2 MIL LAPORTE CO 80535-1446 AGENT NAME: DARYL ALEXANDER INS AGCY INC $1000 DED. COMP. AGENT PHONE: (970)493-2196 $l000 DED. COLL. ENDORSEMENT NO: 6028BT POLICY EFFECTIVE MAY 17 2013 UNTIL TERMINATED POLICY MESSAGES: This policy shown above supersedes policy# 0571122-06M. The policy includes a lose payable clause protecting the additional insured's interest in the described oar to the e)dent of the insurance provided,and subject to all policy provisions. The additional insured will be given 10 days notice if the policy is terminated. Until such notice is provided, it shall be presumed that the required renewal premiums have been paid. The additional insured must notify us within 10 days of o any change of interest or ownership coming to their attention. Failure to do so will render this policy null and void. FRT ADDITIONAL INSURED'S NOTICE; OF COVERAGE State Farm Mutual Automobile Insurance Company NAMED INSURED: POLICY NO: VINEY TRUCKING INC YR/MAKE/MODEL: PO BOX 1446 VIN/CAMPER: LAPORTE CO 80535-1446 AGENT NAME: AGENT PHONE: ENDORSEMENT NO 2157-FAFl-G 057 1122-E17.06N CAR 039 COVERAGE: 2001 PETERBILT TRACTOR BI AND PD LIABILITY 1 XP5D49X11 D550799 $ 2 MIL DARYL ALEXANDER INS AGCY INC $1000 DED. COMP. (970)493.2196 $1000 DED. COLL. 6028BT POLICY EFFECTIVE MAY 17 2013 UNTIL TERMINpTrn POLICY MESSAGES: This policy shown above supersedes policy# 0571122-06M. The policy includes a loss payable clause protecting the additional insured's interest in the described oar to the extent of the insurance provided and subject to all policy provisions. The additional insured will be given 10 days notice if the policy is terminated. Until such notice $is provided, it shall be presumed that the required renewal premiums have been paid. The additional insured must notify us within 10 days of any change of interest or ownership coming to their attention. Failure to do so will render this policy null and void. A. DDITIONAL.INSURED'S.NOTICE OF COVERAGE.: State Farm Mutual Automobile Insurance Company 2157-FAF1-G NAMED INSURED: POLICY NO: 0571122-E17.06N CAR 045 COVERAGE: VINEY TRUCKING INC YR/MAKE/MODEL: 2001 PETERBILT TRACTOR BI AND PD LIABILITY PO BOX 1446 VIN/CAMPER: 1 XPFDB9X61 D563718 I$ 2 MIL LAPORTE CO 80535-1446 AGENT NAME: DARYL ALEXANDER INS AGCY INC $1000 DED. COMP. AGENT PHONE: (970)493-2196 $1000 DED. COLL. ENDORSEMENT NO: 60288T POLICY EFFECTIVE MAY 17 2013 UNTIL TERMINATED POLICY MESSAGES: This policy shown above supersedes policy# 0571.122-06M. The policy includes a loss payable clause protecting the additional insured's interest in the described oar to the extent of the insurance provided and subject to all policy provisions. The additional insured will be given 10 days notice if the policy is terminated. Until such notice is provided, it shall be presumed that the required renewal premiums have been paid. The additional insured must notify us within 10 days of any change of interest or ownership coming to their attention. Failure to do so will render this policy null and void. 0o 0 R ADDITIONAL INSURED'S NOTICE OF COVERAGE State Farm Mutual Automobile NAMED INSURED: VINEY TRUCKING INC PO BOX 1446 LAPORTE CO 80535-1446 Insurance Company POLICY NO: YR/MAKE/MODEL: VIN/CAMPER: AGENT NAME: AGENT PHONE: ENDORSEMENT NO: 057 1122-E17.06N CAR 2001 PETERBILT TRACTOR 1XP5DB9X41D541292 DARYL ALEXANDER INSAGCYINC (970)493-2196 6028BT POLI 2157-FAFl-G o54 COVERAGE: BI AND PD LIABILITY $ 2 MIL $1000 DED. COMP. $1000 DED. COLL. CY EFFECTIVE MAY 17 2013 UNTIL TERMINATED POLICY MESSAGES: This policy shown above supersedes policy# 0571122-06M. The policy includes a lose payable clause protecting the additional insured's interest in the described oar to the extent of the insurance provided and subject to all policy provisions. The additional insured will be given 10 days notice if the policy is terminated. Until such notice is provided, it shall be presumed that the required renewal premiums have been paid. The additional insured must notify us within 10 days of v any change of interest or ownership coming to their attention. Failure to do so will render this policy null and void. 0 ADDITIONAL INSIJRED'S NOTICE OF COVERAGE State Farm Mutual Automobile NAMED INSURED: VINEY TRUCKING INC PO BOX 1446 LAPORTE CO 80535-1446 Insurance Company POLICY NO: YR/MAKE/MODEL: VIN/CAMPER: AGENT NAME: AGENT PHONE: ENDORSEMENT NO: 0571122-E17-06N CAR 2006 TRAVIS TRL DUMP 48X1F392861004289 DARYL ALEXANDER INS AGCY[NO (970)493.2196' 6028BT POLI 2157-FAFt-G 059 COVERAGE: $1000 DED. COMP. $1000 DED. COLL. CY EFFECTIVE MAY 17 2013 UNTIL TERMINATED POLICY MESSAGES: This policy shown above supersedes policy# 0571122-06M. The policy includes a lose payable clause protecting the additional insured's interest In the described oar to the extent of the insurance provided and subject to all policy provisions. The additional insured will be given 10 days notice if the policy is terminated. Until such notice is provided, it shall be presumed that the required renewal premiums have been paid. The additional insured must notify us within 10 days of any change of Interest or ownership coming to their attention. Failure to do so will render this policy null and void. e m W STATE FARM INSURANCE COMPANIES® p RJ 1555 Promontory Circle Greeley CO 80638-0001 9A 20 - 001072 0093 CITY OF FORT. COLLINS FINANCIAL SERVICES PURCHASING DIVISION PO BOX 580 FORT COLLINS CO 80522-0580, s 0 0 0 v N m 0 N O A DATE OF NOTICE: MAY 16 2013 CODE: 33380 NOTE: PLEASE NOTIFY STATE FARM AT THE ADDRESS LISTED AT THE TOP, LEFT CORNER OF THIS PAGE REGARDING ANY CHANGE OF ADDRESS INFORMATION. ADDITIONAL INSURED'SNOTICEOF COVERAGE:; State Farm Mutual Automobile Insurance Company 2157-FAFl-G NAMED INSURED: POLICY NO: 057 1122-El7-06N CAR 063 COVERAGE: o VINEY TRUCKING INC YR/MAKE/MODEL: 2003 KENWORTH TRACTOR BI AND PD LIABILITY N PO BOX 1446 VIN/CAMPER: 1 XKWD89X13J705001$ 2 MIL LAPORTE CO 80535-1446 . AGENT NAME: DARYL ALEXANDER INS AGCY INC $1000 DED. COMP. $1000 DED. COLL. > AGENT PHONE: (970)493.2196 ¢ ENDORSEMENT NO: 6028BT POLICY EFFECTIVE o MAY 17 2013 UNTIL TERMINATED POLICY MESSAGES: This policy shown above supersedes policy# 0571122-06M. The policy includes a loss payable clause protecting the additional insured's interest in the described canto the extent of the insurance provided and subject to all policy provisions. The additional insured will be given 10 days notice if the policy is terminated. Until such notice d is provided, it shall be presumed that the required renewal premiums have been paid. The additional insured must notify we within 10 days of Rany change of interest or ownership coming to their attention. Failure to do so will render this policy null and void. .. e M i State Farm Mutual Automobile Insurance Company 2157-FAF1-G NAMED INSURED: POLICY. NO: 0571122-El7.06N - CAR 065 COVERAGE: VINEY TRUCKING INC YR/MAKE/MODEL: 2003 TRAVIS TRIL $1000 DED. COMP. PO BOX 1446 VIN/CAMPER: 48X1 F382431002603 $1000 DED. COLL. LAPORTE CO 80535-1446 AGENT NAME: DARYL ALEXANDER INS AGCY INC AGENT PHONE: (970)493-2196 ENDORSEMENT NO: 6028BT - POLICY EFFECTIVE MAY 17 2013 UNTIL TERMINATED POLICY MESSAGES: This policy shown above supersedes policy# 0571122-06M. The policy includes a loss payable clause protecting the additional insured's interest in the described oar to the extent of the insurance provided and subject to all policy provisions. The additional insured will be given 10 days notice if the policy is terminated. Until such notice isprovided, it shall be presumed that the required renewal premiums have been paid. The additional insured must notify us within 10 days of any change of interest or ownership coming to their attention.- Failure to do so will render this policy null and void. A ADDITIONAL INSURED'S NOTICE: OF COVERAGE !: State Farm Mutual Automobile Insurance Company 2157-FAFl-G NAMED INSURED: POLICY NO: 0671122-E17-06N CAR 070 COVERAGE: VINEY TRUCKING INC YR/MAKE/MODEL: 2005 PETERBILT TRACTOR el AND PD LIABILITY PO BOX 1446 VIN/CAMPER: 1 XP5D89X15D846500 $ 2 MIL LAPORTE CO 80535-1446 AGENT NAME: DARYL ALEXANDER INS AGCY INC $1000 DED. COMP. $1000 DED. COLL. AGENT PHONE: (970)493-2196 ENDORSEMENT NO: 6028BT POLICY EFFECTIVE MAY 172013 UNTIL TERMINATED POLICY MESSAGES: This policy shown above supersedes policy# 0571122-06M. The policy includes a loss payable clause protecting the additional insured's interest in the described car to the extent of the insurance provided and subject to all policy provisions. The additional insured will be given 10 days notice if the policy is terminated. Until such notice isprovided, it shall be presumed that the required renewal premiums have been paid. The additional insured must notify us within 10 days of any change of interest or ownership coming to their attention. Failure to do so will render this policy null and void. m FRT State Farm Mutual Automobile Insurance Company NAMED INSURED: - POLICY NO: VINEY TRUCKING INC YR/MAKE/MODEL: PO BOX 1446 VIN/CAMPER: LAPORTE CO 80535.1446 AGENT NAME: AGENT PHONE: ENDORSEMENT NO: 2157-FAF1-G 057 1122-E17-06N CAR 071 COVERAGE: 2005 PETERBILT TRACTOR BI AND PD LIABILITY 1XP5DB9X55D856513. $ 2 MIL DARYLALEXANDER INS AGCY INC $1000 DED. COMP. $1000 DED.COLL. (970)493-2196 6028BT POLICY EFFECTIVE MAY 17 2013 UNTIL TERMINATEn POLICY MESSAGES: This policy shown above supersedes policy# 0571122-06M. The policy includes a lose payable clause protecting the additional insured's interest in the described oar to the extent of the insurance provided and subject to all policy provisions. The additional insured will be given 10 days notice if the policy is terminated. Until such notice $is provided, it shall be presumed that the required renewal premiums have been paid. The additional insured must notify us within 10 days of any change of interest or ownership coming to their attention. Failure to do so will render this policy null and void. R "ADDITIONAL INSURED'S'NOTICEOF COVERAGE State Farm Mutual Automobile NAMED INSURED: VINEY TRUCKING INC . PO BOX 1446 LAPORTE CO 80535.1446 Insurance Company POLICY NO: YR/MAKE/MODEL: VIN/CAMPER: AGENT NAME: AGENT PHONE: ENDORSEMENT NO: 2157-FAF1-G 057 1122-E17.06N . I CAR 072 COVERAGE: 2008 TRAIL KING TRAILER $1000 DED. COMP: 1 TKL041258WO38627 $1000 DED. COLL.. DARYLALEXANDERINS AGCYINC (970)493-2196 6028BT POLICY EFFECTIVE MAY 172013 UNTIL TERMINATED POLICY MESSAGES: This policy shown above supersedes policy# 0571122.06M. The policy includes a loss payable clause protecting the additional insured's interest in the described oar to the extant of the insurance provided and subject to all policy provisions. The additional insured will be given 10 days notice if the policy is terminated. Until such notes is provided, it shall be presumed that the required renewal premiums have been paid. The additional insured must notify us within 10 days of V any change of interest or ownership coming to their attention. Failure to do so will render this policy null and void. m ADDITIONAL INSURED'S:NOTICE;OF COVERAGE State Farm Mutual Automobile Insurance Company 2157-FAF1-G NAMED INSURED: POLICY NO: 0571122-E17-06N CAR 073 COVERAGE: VINEY TRUCKING INC - YR/MAKE/MODEL: 2004 PETERBILT TRACTOR BI AND PD LIABILITY PO BOX 1446 VIN/CAMPER: 1 XP5DB9X94D818538 $ 2 MIL LAPORTE CO 80535-1446 AGENT NAME: DARYL ALEXANDER INS AGCY INC $1000 DED. COMP: AGENT PHONE: (970)493-2196 $l000 DED. cot L. ENDORSEMENT NO: 6028BT POLICY EFFECTIVE MAY 17 2013 UNTIL TERMINATED POLICY MESSAGES: This policy shown above supersedes policy# 0571122-06M. The policy includes a lose payable clause protecting the additional insured's interest in the described oar to the extent of the insurance provided and subject to all policy provisions. The additional insured will be given 10 days notice if the policy is terminated. Until such notice is provided, it shall be presumed that the required renewal premiums have been paid. The additional insured must notify us within 10 days of any change of interest or ownership coming to their attention. Failure to do so will render this policy null and void: CO q ADDITIONAL INSURED'S NOTICE OF COVERAGE State Farm Mutual Automobile Insurance Company 2157-FAFI-G NAMED INSURED: POLICY NO: 0571122-El7.06N CAR 074 COVERAGE: VINEY TRUCKING INC YR/MAKE/MODEL: 2008 TRAIL KING TRL DUMP $1000 DED. COMP. PO BOX 1446 VIN/CAMPER: 1 TK8040228WO54961 $1000 DED. COLL. LAPORTE CO 80535-1446 AGENT NAME: DARYLALEXANDER INS AGCY INC AGENT PHONE: (970)493-2196 ENDORSEMENT NO: 6028BT POLICY EFFECTIVE MAY 17 2013 UNTIL TERMINATED POLICY MESSAGES: This policy shown above supersedes policy# 0571122-06M. The policy includes a loss payable clause protecting the additional insured's interest in the described oar to the e:dent of the insurance provided and subject to all policy provisions. The additional insured will be given 10 days notice if the policy is terminated. Until such notes is provided, it shall be presumed that the required renewal premiums have been paid. The additional insured must notify us within 10 days of any change of interest or ownership coming to their attention. Failure to do so will render this policy null and void. BCKI STATE FARM INSURANCE COMPANIES® 1655 Promontory Circle DATE OF NOTICE: MAY 16 2013 Greeley CO 80638-0001 CODE: 33380 9A 20 A 001072 0093 CITY OF FORT COLLINS FINANCIAL NOTE: PLEASE NOTIFY STATE FARM AT THE SERVICES PURCHASING DIVISION ADDRESS LISTED AT THE TOP, LEFT CORNER PO BOX 580 OF THIS PAGE REGARDING ANY CHANGEOF Ffftli FORT COLLINS CO 80522-0580 ADDRESS INFORMATION. BIER OITI6NAL.INSURED!g�'NOTIbEDFCOVERAGE; .. ..... ............. 7 . State Farm Mutual Automobile Insurance Company 2157-FAFl-G NAMED INSURED: POLICY NO: 057 1122-EI7-06N CAR 075 COVERAGE: o VINEY TRUCKING INC YR/MAKE/MODEL: 2005 KENWORTH TRACTOR 81 AND PD LIABILITY PO BOX 1446 VINI/CAMPER: IXKWDB9X95R096258 $ 2 MIL$1000 DED. COMP. LAPORTE CO 80535-1446 AGENT NAME: DARYL ALEXANDER INS AGICY INC $1000 DED. COLL. AGENTPHONE: (970)493-2196 ENDORSEMENT NO: 6028BT POLICY EFFECTIVE o MAY 17 2013 UNTIL TERMINATED POLICY MESSAGES: This policy shown above supersedes policy# 0571122-06M. The policy includes a lose payable clause protecting the additional insured's interest in the described oar to the extent of the insurance provided and subject to all policy provisions. The additional insured will be given 10 days notice if the policy is terminated. Until such notice wi is provided, it shall be presumed that the required renewal premiums have been paid. The additional insured must notify us within 10 days of any change of interest or ownership coming to their attention. Failure to do so will render this policy null and void. . ...................... ........................... ...... .................... ADDITIONAL lbITIONAL:. I. .N. . SURED'.S.7:N: O7: TICEI.OF:COVERAGE::,. . . . . . . . . . . . . . . . . . . . ... . . . ...... X.: : I.... .. ...%.., ............ . . . . . . . . State Farm Mutual Automobile Insurance Company 2157-FAFI-G NAMED INSURED: POLICY NO: 057 1122-E17-06N CAR 076 COVERAGE: VINEY TRUCKING INC YR/MAKE/MODEL: 2008 TRAIL KING TRAILER $1000 DED. COMP. PO BOX 1446 VINI/CAMPER: 1 TK8040268WO54963 $1000 DED. COLL. LAPORTE CO 80535-1446 AGENT NAME: DARYL ALEXANDER INS AGGY INC AGENT PHONE: (970)493-2196 ENDORSEMENT NO: 60288T POLICY EFFECTIVE MAY 17 2013 UNTIL TERMINATED POLICY MESSAGES: This policy shown above supersedes policy# 0571122-06M. The policy includes a loss payable clause protecting the additional insured's interest in the described oar to the extent of the Insurance provided and subject to all policy provisions. The additional insured will be given 10 days notice if the policy is terminated. Until such notice is provided, it shall be presumed that the required renewal premiums have been paid. The additional insured must notify us within 10 days of any change of interest or ownership coming to their attention. Failure to do so will render this policy null and void. ................... ........... ........... �.ADDITIONAL :IINSURED'S:NO,TICEOF: COVERAGE::::: ........................... .... .......... State Farm Mutual Automobile Insurance Company 2157-FAFI-G NAMED INSURED: POLICY NO: 057 1122-E17-06N CAR 079 COVERAGE: VINEY TRUCKING INC YR/MAKE/MODEL: 2001 PETERBILT TRACTOR BI AND PD LIABILITY PO BOX 1446 VIN/CAMPER: 1 XPFDB9X41 N541260 $ 2 MIL LAPORTE CO 80535-144$1000 DED. COMP.6 AGENT NAME: DARYL ALEXANDER INS AGGY INC $1000 DED. COLL. AGENT PHONE: (970)493-2196 ENDORSEMENT NO: 6028ST POLICY EFFECTIVE MAY 17 2013 UNTIL TERMINATED POLICY MESSAGES: This policy shown above supersedes policy# 0571122-06M. The policy includes a lose payable clause protecting the additional insured's interest in the described oar to the extent of the insurance provided and subject to all policy provisions. The additional insured will be given 10 days notice it the policy is terminated. Until such notice is provided, it shall be presumed that the required renewal premiums have been paid. The additional insured must notify us within 10 days of any change of interest or ownership coming to their attention. Failure to do so will render this policy null and void. FRT ADDITIONAL INSURED'S NOTICE:OF COVERAGE State Farm Mutual Automobile Insurance Company 2157-FAFl-G NAMED INSURED: POLICY NO: 0571122-E17.06N CAR 080 COVERAGE: VINEY TRUCKING INC YR/MAKE/MODEL: 2004 KENWORTH TRACTOR BI AND PD LIABILITY PO BOX 1446 VIN/CAMPER: 1 XKWDB9X04R065303 $ 2 MIL LAPORTE CO 80535-1446 AGENT NAME: DARYL ALEXANDER INS AGCY INC $1000 DED. COMP. $1000 DED. COLL. AGENT PHONE: (970)493-2196 ENDORSEMENT NO. 6028ST POLICY EFFECTIVE POLICY MESSAGES: This policy shown above supersedes policy# 0571122.06M. MAY 17 2013 UNTIL TERMINATED The policy includes a lose payable clause protecting the additional insured's interest in the described car to the e)dent of the insurance provided and subject to all policy provisions. The additional insured will be given 10 days notice if the policy is terminated. Until such notice $is provided, it shall be presumed that the required renewal premiums have been paid. The additional insured must notify us within 10 days of a any change of interest or ownership coming to their attention. Failure to do so will render this policy null and void. a R ADDITIONAL INSURED'S.NOTICE:OF COVERAGE State Farm Mutual Automobile Insurance Company 2157-FAF1-G NAMED INSURED: POLICY NO: 057 1122-E17-06N CAR 081 COVERAGE: VINEY TRUCKING INC YR/MAKE/MODEL: NONOWNED AUTO BI AND PD LIABILITY PO BOX 1446 VIN/CAMPER: $ 2 MIL LAPORTE CO 80535-1446 AGENT NAME: DARYL ALEXANDER INS AGCY INC AGENT PHONE: (970)493-2196 ENDORSEMENT NO: 6028BT POLICY EFFECTIVE 6164CR 6165BT MAY 17 2013 UNTIL TERMINATED POLICY MESSAGES: This policy shown above supersedes policy# 0571122-06M. The policy includes a loss payable clause protecting the additional insured's interest in the described oar to the e)dent of the insurance provided and subject to all policy provisions. The additional insured will be given 10 days notice if the policy is terminated. Until such notice is provided, it shall be presumed that the required renewal premiums have been paid. The additional insured must notify us within 10 days of yt any change of interest or ownership coming to their attention. Failure to do so will render this policy null and void. 0 m 4 BCKI STATE FARM INSURANCE COMPANIES` b 1555 Promontory Circle Greeley CO 80638-0001 15A AT1 20 A 000962 0093 CITY OF FORT COLLINS FINANCIAL SERVICES PURCHASING DIVISION r PO BOX 580 FORT COLLINS CO 80522-0580 z 0 0 F N N O O DATE OF NOTICE: MAY 17 2013 CODE: 33380 NOTE: PLEASE NOTIFY STATE FARM AT THE ADDRESS LISTED AT THE TOP,.LEFT CORNER OF THIS PAGE REGARDING ANY CHANGE OF ADDRESS INFORMATION. State Farm Mutual Automobile Insurance Company 2157-FAFl-G NAMED INSURED: POLICY NO:` 0571122-E17.06N CAR 013 COVERAGE: e VINEY TRUCKING INC YR/MAKE/MODEL: 1997 PETERBILT TRACTOR BI AND PD LIABILITY N PO BOX 1446 VIN/CAMPER: 1 XP5DB8X2VD433065 $ 2MIL $1000 DED. COMP. LAPORTE CO 80535.1446 AGENT NAME: DARYL ALEXANDER INS AGCY INC $1000 DED. COLL. > AGENT PHONE: (970)493-2196 ENDORSEMENT NO: 6028BT POLICY EFFECTIVE 0 MAY 17 2013 UNTIL TERMINATED POLICY MESSAGES: This policy shown above supersedes policy# 0571122-06M. R The policy includes a loss payable clause protecting the additional insured's interest in the described canto the extent of the insurance provided and subject to all policy provisions. The additional insured will be given 10 days notice if the policy is terminated. Until such notice ,A is provided, it shall be presumed that the required renewal premiums have been paid. The additional insured must notify us within 10 days of any change of interest or.ownership coming to their attention. Failure to do so will render this policy null and void. d . o� State Farm Mutual Automobile Insurance Company - 2157-FAF1-G NAMED INSURED: POLICY NO: 0571122-E17-06N CAR 023 COVERAGE:.. VINEY TRUCKING INC YR/MAKE/MODEL: - 1994 PETERBILT TRACTOR BI AND PD LIABILITY PO BOX 1446 VIN/CAMPER: 1XP5DR9X7RD347.733 • $ 2 MIL LAPORTE CO 80535-1446 AGENT NAME: DARYL ALEXANDER INS AGCY INC $1000 DED. COMP. AGENT,PHONE:- (00)493-2196 $t000 DED. COLL. — — — — -- --ENDORSEMENT-NO: 602813T -__- —POLICY-EFFECTIVE__ MAY 17 2013 UNTIL TERMINATED POLICY MESSAGES: This policy shown above supersedes policy# 0571122-06M. The policy includes a loss payable clause protectingthe additional insured's interest in the described oar to the extent of the insurance provided and subject to all policy provisions. The additional insured will be given 10 days notice it the policy is terminated. Until such notice is provided, it shall be presumed that the required renewal premiums have been paid. The additional insured must notify us within 10 days of any change of interest or ownership coming to their attention. ,Failure to do so will render this policy null and void. A ADDITIONAL INSURED'SNOTICEOF COVERAGE:'! State Farm Mutual Automobile Insurance Company 2157-FAF1-G NAMED INSURED: POLICY NO: 0571122-E17-06N CAR 033 COVERAGE: VINEY TRUCKING INC YR/MAKE/MODEL: 1996 PETERBILT TRACTOR BI AND PD LIABILITY PO BOX 1446 VIN/CAMPER: 1 XPFDB9X4TD398321 $ 2MIL LAPORTE Co 80535-1446 AGENT NAME: DARYL ALEXANDER INS AGCY INC $1000 DED. COMP. $1000 DED. LOLL. AGENT PHONE: (970)493.2196 _ ENDORSEMENT NO: 6028BT POLICY EFFECTIVE MAY. 17 2013 UNTIL TERMINATED POLICY MESSAGES: This policy shown above supersedes policy# 0571122-06M.. The policy includes a loss payable clause protecting the additional insured's interest in the described oar to the extent of the insurance provided and subject to all policy provisions. The additional insured will be given 10 days notice if the policy is terminated. Until such notice is provided, it shall be presumed that the required renewal premiums have been paid. The additional insured must notify us within 10 days of any change of interest or ownership coming to their attention. Failure to do so will render this policy null and void. FRT ADDITIONAL INSURED'S NOTICE;OF COVERAGE State Farm Mutual Automobile Insurance Company 2157-FAFt-G NAMED INSURED: POLICY NO: 0571122-El7.06N CAR 039 COVERAGE: VINEY TRUCKING INC YR/MAKE/MODEL: 2001 PETERBILT TRACTOR BI AND PD LIABILITY PO BOX 1446 VIN/CAMPER: 1 XP5D49X11 D550799 $ 2 MIL LAPORTE CO 80535-1446 AGENT NAME: DARYL ALEXANDER INS AGCY INC $1000 DED. COMP. AGENT PHONE: (970)493-2196 $1000 DED. COLL, ENDORSEMENT NO: 6028BT POLICY EFFECTIVE POLICY MESSAGES: This policy shown above supersedes policyi 0571122-06M. MAY 17 2013 UNTIL TERMINATED The policy includes a loss payable clause protecting the additional insured's interest in the described car to the extent of the insurance provided and subject to all policy provisions. The additional insured will be given 10 days notice if the policy is terminated. Until such notice $is provided, it shall be presumed that the required renewal premiums have been paid. The additional insured must notify us within 10 days of any change of interest or ownership coming to their attention. Failure to do so will render this policy null and void. 9 iQ m 9 mN O e ADDITIONAL INSURED'S NOTICE OF COVERAGE State Farm Mutual Automobile Insurance Company 2157-FAFl-G NAMED INSURED: POLICY NO: 657 1122-E17-06N CAR 045 COVERAGE: VINEY TRUCKING INC YR/MAKE/MODEL: 2001 PETERBILT TRACTOR BI AND PD LIABILITY PO BOX 1446 VIN/CAMPER: 1 XPFDB9X61 D563718 $ 2 MIL LAPORTE CO 80535-1446 AGENT NAME: DARYL ALEXANDER INS AGCY INC $1000 DED. COMP.. $1000 DED. COLL. AGENT PHONE:. (970)493-2196 ENDORSEMENT NO: 6028BT POLICY EFFECTIVE MAY 17 2013 UNTIL TERMINATED POLICY MESSAGES: This policy shown above supersedes policy# 0571122-06M. The policy includes a loss payable clause protecting the additional insured's interest in the described oar to the extent of the insurance provided and subject to all policy provisions. The additional insured will be given 10 days notice if the policy is terminated. Until such notice is provided, it shall be presumed that the required renewal premiums have been paid. The additional insured must notify us within 10 days of any change of interest or ownership coming to their attention. Failure to do so will render this policy null and void. ADDITIONAL INS6RED'S NOTICE OF COVERAGE. State Farm Mutual Automobile Insurance Company NAMED INSURED: POLICY NO: VINEY TRUCKING INC YR/MAKE/MODEL: PO BOX 1446 VIN/CAMPER: LAPORTE 00 80535-1446 AGENT NAME: AGENT PHONE: ENDORSEMENT NO: 2157-FAFl-G 057 1122-E17.06N CAR 054 COVERAGE: " 2001 PETERBILT TRACTOR BI AND PD LIABILITY 1 XP5DS9X41 D541292 $ 2 MIL DARYL ALEXANDER INS AGCY INC $1000 DED. COMP. $1000 DED. COLL. (970)493-2196 . 6028BT POLICY EFFECTIVE MAY 17 2013 UNTIL TERMIN07cn POLICY MESSAGES: This policy shown above supersedes policy# 0571122-06M. The policy includes a lose payable clause protecting the additional insured's interest in.the described car to the eident of the insurance provided and subject to all policy provisions. The additional insured will be given 10 days notice if the policy is terminated. Until such notice is provided, it shall be presumed that the required renewal premiums have been paid. The additional insured must notify us within 10 days of any change of interest or ownership coming to their attention. Failure to do so will.render this policy null and void. ADDITIONAL INSURED'S NOTICE OF COVERAGE State Farm Mutual Automobile Insurance Company 2157-FAF1-G NAMED INSURED: POLICY NO: VINEY TRUCKING INC YR/MAKE/MODEL: PO BOX 1446 VIN/CAMPER: LAPORTE CO 80535-1446 AGENT NAME: AGENT PHONE: ENDORSEMENT NO: 057 1122-E17-06N r CAR 063 COVERAGE: 2003 KENWORTH TRACTOR BI AND PD LIABILITY 1 XKWD89X13J705001 $ 2 MIL $1000 DED. COMP. DARYL ALEXANDER INS AGCY INC $1000 DED. COLL.- (970)493-2196 6028BT POLICY EFFECTIVE MAY 17 2013 UNTIL TERMINATED POLICY MESSAGES: This policy shown above supersedes policy# 0571122-06M The policy includes a loss payable clause protecting the additional Insured's interest in the described oar to the e)dent of the insurance provided and subject to all policy provisions. The additional insured will be given 10 days notice if the policy is terminated. Until such notice is provided, it shall be presumed that the required renewal premiums have been paid. The additional insured must notify us within 10 days of any change of interest or ownership coming to their attention. Failure to do so will render this policy null and void. am STATE FARM INSURANCE COMPANIESQ1 ADATE OF NOTICE: MAY 17 2013 7555 Promont806oryryCirc101 CODE: 33380 Greeley CO 38-00 15A 20 A 000sez Dose NOTE: PLEASE NOTIFY STATE FARM AT THE CITY OF FORTCOLLINSFINANCIAL ADDRESS LISTED AT THE TOP, LEFT CORNER PO SERVICES PURCHHASINGASINGDIVISION X 580 OF THIS PAGE REGARDING ANY CHANGE OF € FORT OCOLLINS CO 80522-0580 ADDRESS INFORMATION. 0 N ADDITIONAL.INSURED'S NOTICE OF COVERAGE State Farm Mutual Automobile Insurance Company 2157-FAF1-G NAMED INSURED: POLICY NO: 0571122-E17-06N CAR 065 COVERAGE: e VINEY TRUCKING INC YR/MAKE/MODEL: 2003 TRAVIS TRL $1000 DED. COMP. PO BOX 1446 VIN/CAMPER: 48X1 F382431002603 $1000 DED. COLL. LAPORTE CO 80535-1446 AGENT NAME: DARYL ALEXANDER INS AGCY INC AGENT PHONE: (970)493-2196 ENDORSEMENT NO: 6028BT POLICY EFFECTIVE o' MAY 17 2013 UNTIL TERMINATED N POLICY MESSAGES: This policy shown above supersedes policy* 0571122-06M. The policy includes a lose payable clause protecting the additional insured's interest in the described car to the extent of the insurance provided and subject to all policy provisions. The additional insured will be given 10 days notice if the policy is terminated. Until such notice ui is provided, it shall be presumed that the required renewal premiums have been paid. The additional insured must notify us within 10 days of any change of interest or ownership coming to their attention. Failure to do so will render this policy null and void. e n State Farm Mutual Automobile Insurance Company 2157-FAF1-G NAMED INSURED: POLICY NO: 0571122-E17-06N CAR 079 COVERAGE: VINEY TRUCKING INC YR/MAKE/MODEL: 2001 PETERBILT TRACTOR BI AND PC LIABILITY PO BOX 1446 VIN/CAMPER: 1 XPFD89X41 N541260 $ 2 MIL LAPORTE CO 80535-1446 AGENT NAME: DARYL ALEXANDER INS AGCY INC $1000 DED. COMP. $1000 DED. COLL, AGENT PHONE: (970)493-2196 ENDORSEMENT -NO: 6028BT - -- - - - POLICY -EFFECTIVE MAY 17 2013 UNTIL TERMINATED POLICY MESSAGES: This policy shown above supersedes policy* 0571122-06M. The policy includes a lose payable clause protecting the additional insured's interest in the described car to the extent of the insurance provided and subject to all policy provisions. The additional insured will be given 10 days notice if the policy is terminated. Until such notice is provided, it shall be presumed that the required renewal premiums have been paid. The additional insured must notify us within 10 days of any change of interest or ownership coming to their attention. Failure to do so will render this policy null and void. e State Farm Mutual Automobile Insurance Company 2157-FAF1-G NAMED INSURED: POLICY NO: 0571122-E17-06N CAR 081 COVERAGE: VINEY TRUCKING INC YR/MAKE/MODEL: NONOwNED AUTO BI AND PD LIABILITY PO BOX 1446 VIN/CAMPER: $ 2 MIL LAPORTE CO 80535-1446 AGENTNAME: DARYL ALEXANDER INS AGCY INC AGENTPHONE: (970)493-2196 ENDORSEMENT NO: 6028BT POLICY EFFECTIVE 6164CR 6165BT MAY 172013 UNTIL TERMINATED POLICY MESSAGES: This policy shown above supersedes policy* 0571122-06M. The policy includes a lose payable clause protecting the additional insured's interest in the described oar to the extent of the insurance provided and subject to all policy provisions. The additional Insured will be given 10 days notice If the policy is terminated. Until such notice is provided, it shall be presumed that the required renewal premiums have been paid. The additional insured must notify us within 10 days of any change of interest or ownership coming to their attention. Failure to do so will render this policy null and void. q FRT Apr 21 1302:35p VINEY 970-493-6263 Piney Trucking, Inc. PO-tox -1446 LOPOM CO 80535 Office (970) 493 1403 Fax (970) 493-6263 Ernm7 Wn6Yh7WRng@M=Com fmX#;.jIlrtl t jJ Q a4 GA- Fax Number- .2021--1 70 7 Pages Including Covet -7-S - , j "-0i3 WNW, Kevin Viney 1y 970�93-1403 Cell970-219-1785 P.O. Box 1446 ct� ItoLaporte, CO 60535' Fax 970.493-6263 vinayaucicng@msn-co Founded By Duane Viney in 1957 0 OF IU: KIM CERTIFICATE OF LIABILITY INSURANCE 05/0812013 O5/0812013 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 endorsements . PRODUCER Phone: 970-635-9400 PFS Insurance Group -JT 4848 Thompson Pkwy, Ste 200 Fax: 970-635-9401 Johnstown, CO 80534 Tad Borrett CONTACT PHCNN., FA% AIE:t : ac No E-MAIL ADDRESS: PRODUCER VINEY-1 CUSTOMER ID k: INSURERS AFFORDING COVERAGE NAIC N INSURED Viney Trucking, Inc. INSURER A: Pinnacol Assurance 41190 P.O. Box 1446 LaPorte, CO 80535 INSURER 8: INSURER C INSURER D INSURER E INSURER F : COVERAGES CERTIFICATE 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 LTR TYPE OF INSURANCE OL UB POLICY NUMBER MMIDOPOLICY/YYYY EFF MMIDDfICYYYY Y LIMITS GENERAL LIABILITY COMMERCIAL GENERAL LIABILITY CLAIMS-MADE1:1 OCCUR N/A EACH OCCURRENCE $ $ DAMWTE PREMISES Ea occurrence REMISES Ea occur MED EXP(Anyone person) $ PERSONAL B ADV INJURY $ GENERAL AGGREGATE $ GEN'L AGGREGATE LIMIT APPLIES PER: POLICY F7 PRO LOC ECIT PRODUCTS - COMPIOP AGG $ $ AUTOMOBILE LIABILITY ANY AUTO ALL OWNED AUTOS SCHEDULED AUTOS HIRED AUTOS NON -OWNED AUTOS N/A COMBINED SINGLE LIMIT (Ea accident) $ BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ PROPERTY DAMAGE (Peraccident) $ $ $ UMBRELLA LIAB EXCESS LIAB OCCUR CLAIMS -MADE N/A EACH OCCURRENCE $ AGGREGATE $ DEDUCTIBLE - RETENTION $ 4 $ A WORKERS COMPENSATION AND EMPLOYERS' LIABILITY AN V PROPRIETORIPARTNERIEXECUTIVE Y I❑N OFFICER/MEMBER EXCLUDED? (Mandatory in NH) If yes describe under DESCRIPTION OF OPERATIONS below NIA 1963162 BLKT WAIVER OF SUBROGATIO 06/0112013 06101/2014 X WC STATU- I OTH- E.L. EACH ACCIDENT $ 100,000 E. L. DISEASE -EA EMPLOYE 8 100,000 E.L. DISEASE -POLICY LIMIT $ 600,000 0,512012001 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101, Additional Remarks Schedule, it more Space is required) CITYFCC City of Fort Collins Attn: Purchasing Department P O Box 580 Fort Collins, CO 80521 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 V TSaB-21JU11 AUUKU UUKPUKATION. All rights reSerVed. ACORD 25 (2009/09) The ACORD name and logo are registered marks of ACORD 02/08/2007 19: 59 9702215478 DARYLALEXANDER PAGE 02/02 ,wOr CERTIFICATE OF LIABILITY INSURANCE ""'o4iaTrzois" THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE MOLDER. 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(SL AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: it the cortMCate holder is an ADDITIONAL INSURED, the pollcy(les) must be andomed. If SUBROGATION 19 WAIVED, subject to the terms and Conditions of the policy, certain policies mry require an andomemem- A statement on this cartNlpta does not confer rights to the gDD �R DARYL ALEXANDER INS AGCY INC 6205 S COLLEGE AVE S &Rwm FORT COLLINS, CO 80625 B. INSURED VINEY TRUCKING INC PO BOX 1446 LAPORTE CO 80535-1446 seArvR PeeTeV-wTC nuunce. ONIQIMI MI IuRPO• 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 SMOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. TYPE OF INSLRNNCE POLICY NUABFR UMITS GENERALLIABAIT'r COMMERCIAL GENERAL LIAGUTY CLAIMS- OE f7OCCUR EACk OCLVRRENCE _ f P„SEMIREB.IEB.RS.agELao MCO EAP (Airy PIIBPMm S S PERSONAL S AOV RUURY S GENERAL AGGREGATE i GEM AGGREGATE POLICY LIMIT APPLIES PER: PRO- LOC PROOUCTS-COMPATPAGD S S A AUTOMOBILE UARrt1TY ANY AUTO ALL OWNED FZ71X SCHEDULED �X HIRED AUTOS X �LIjTOSi- - Y 06-111224E17461111 06M7JY013 O6f1712014 W _[P.a Rmleevl LIMIT 90CILY WIRY (P. S ZOOO.DOO SOGItY INJURY IPw reRaPnO S ~yT f UMBRELLA LAS EIICE93LU1a OCCUR CURA1NADt EACHOCCURRENCE $ AGGREGATE S owRul DNS y` S N'pRRERS COMPH�ISATMIN AND EMPLOYERS' UARKAY- ANY PROPRIETORFAPTNERIEJIECUTNE YIN OFICEAIEMBER E%CLuOEpt (MFnbtmMmO I YCt, CEIOla VWPr NIA WD tlTAW 0 .0$Y LLWI. B EL EACH ACCIDENT S E.L OSEASE-EA ENPLOY S E L O14EA9E-POLICY I.IMrt -_.- i OE9CPIP1ftON W OPOUTImni I LOCATIONS I vE1YCLZe(ARKA ACORD Set, A Iffl I fflft ae ft. Ninert pure MreRVM) CRY OF FORT COLLINS FINANCIAL SERVICES PURCHASING DIVISION IS LISTED AS ADDITIONAL INSURED. CITY OF FORT COLLINS FINANCIAL SERVICES PURCHASING OMSION PO BOX 580 FORT COLLINS CO 60522-OSOO SHOULD ANY OF THE ABOVE DESCRIBED POLICIES DE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE ML BE DELNERED IN ACCORDANCE WITH THE POLICY PROV=NS. �,QQ/�_ ACORD 25 (2010105) The ACORO name and logo are registered marks of AOORD 1001486 132649.8 01.23-2013 APR-25-2010 08:29 OCCUPATIONAL HEALTH 970 297 6599 P.004 OP ID' MR .a�aav CERTIFICATE OF LIABILITY INSURANCE 7A7(NNp0WY) 04122f2013 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER, TMIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED 8Y THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUINGI INSURER(SL AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: N the certificate holder IS an ADDITIONAL INSURED, the poUCy(Ie5) must De endor5e0. if SUBROGATION IS WAIVED, sub)ud to the terms and conditions of the Policy. Certain policies may require an endorsement. A StatOrtant on this certificate (does not cainfer rights to the Certificate holder In Hou of such endorsements . PRODUCER Phone: 970-635-940 PFS Insurance Group -JT Fax: 870$56�9401 4940 Thompson ", Ste 200 Johnstown, CO 80534 Tad Boas" - N b F ry -MA�ILgg PRe011cg VINEY•1 INIRIKERM AFFORDING COVERAGE NNCd INSURED ,VInay Trucking,Inc. INSURERA:PinnaeolAssurance 41190 P.O. Box 1446 LaPorte, CO 80635 INSURER 6: IRsuRER c: INSURER 0: INeUR6ie: I N F- rnvranr'cfY rcwnRlreTs NI Iuwco- onflanu Nlluoco. THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE NSUREO NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAN, THE INSURANCE AFFORDED BY THE POLICES DESCRIBED HEREIN G SUBJECT TO ALL THE TERMS, EXCLUSIONSAND CONDITIONS OF SUCH POLICIES- LIMITS SHOWN MAYHAVE BEEN REDUCED BY PAID CLAIMS, TYPEOFINSURANCE I X LIMITS GENERAL LIABILITY EACH O=RRENCE f f COMMEROAL GENERAL a 8guTY NIA CLAA,ISMADE ❑OCCUR NEDEfP tiaa arson I PERSONAL & ADV NAM t GENEItAL AGGREGATE f CF AGGREGATE LIMIT APPLLEOPER PRODUCTS. C6MPIOP ACC S Pow- PA0. JEU LOC S AUTOMOBILE UADILRV ANY AUTO ALL MNEDAUTOS IA " COMUVEO S4461E LNII (EO ectlOwO S BODILY N,IURYI(Pw pawn) S BODILY INJURY(Pw a¢idenl) S SCNEOULEO AUTOS HIREDAUTOS PROPERTY DAMAGE rya ncTitlanO t f Nov -OWNED AUTOS I f USIBRELLA W11 EACH OCQJRRENCE S EXC65SUAD CLIIAW NIA AOCREOATE I OEWCTIBI.E f f A WORKI?ItSGOMIENEATON ANY ENFL 1(FrOR AgITNE Y in �ICEPaIO�bVF,)0 TVG�F,m OJmE Y❑ IMandaturl, h, NH) ILIA 1963162 EILM WAIVER OF eVOROGA'TO a8101/2MZ OSRIII X WCSTATLL OBI" EL EAC 1ACODENT S TDO, c,L.OGEASC-CA CMPLOYC I ID10,000 Gyypps Ri-M. 0V00' OESCRIPnON OE OPERATIONS bNPa EL. p.SEASE- POLICY IJMT S 500,00 D 12111200'I � D"CRFTONOF OPEDATONS t LOCATIONS I VEHICLES (Attach ACORD Sef,Aaadwml Ramm"ItChtdYlt, if mart •pttt 6 r"iman CITYFCC I SHOULD ANY OF THE ABOVE DE$CR18E0 POLICIES BE CANCEU.ED BEFORE THE DWM71ON DATE THEREOF, NOTICE WILL BE OELNERED) IN City of Fort Collins ACCORDANCE TNIH YHE POLICY FROVISIONttt Attn: Purchasing Department P O Box 580 AUTHORUEDREPRESENTATNE Fort Collins, CO 00521 (D 19804009 ACORD CORPORATION, All rights reserved. ACORO 25 (2009l09) The ACORD name and logo are registered marks of ACORD TYITAT. P nnA APR-25-2013 12:04 OCCUPATIONAL HEALTH 970 297 6599 P.002 Concenitm, treated right Impro✓vtq America's health, one "Al at a lime. Concen ra Fort Collins 0618 620 South Lemay Avenue Fort Coffins, CO 80524 Phone (970) 221-5811 Fox 970 =-5817 FAX To: V I kakRom: Phone: Date: Re: CC. Comments: ��^(1�b�2i2�Cpur1-� I i i this fox cover sheet or Content may contain promotional Information about products or seMceslotfered by Concentra. If you would Ilke to dlscontln00 receipt of these promotional announcements, please fellowrnese simple steps: I Write your complete fax number here; .1 )Check mark here to confirm your request mot The sox number above not be used r0 send promothfwl messages from Concentra. Thts will discontinue only those farces or cover sheets that contain a promotional message. Concentra, In accordance with the FCC, recognises that failure to comply with your request wrhfn 30 days, Is twowful. Return this completed Informatlon via; Fax to: 9702214$17 Coll to: 970-221-Se1 I Small to: Cloudlo_oleary®coneenlna.com —" CONnaatTIAl"y NOTICE— NOTICE This Cammunlcalion Is conl1dantfal and 4Intended Only {er the person named above. Np Or1e Olhar )hen the nomoa recipient u oufhortred to use the 611`00710flon ContdM*d herein In any manner. If you hove received tht communication in error, please coil the sender fcalle l 0 necanmv) to Identity the error. If YOU have rocelved This commurGcotlen In error, please telephone Concenrro's HIPAA Hotline ar 972-725-6676. APR-25-2013 12:00 96% P.001 APR-25-2013 12:04 OCCUPATIONAL HEALTH 970 297 6599 P.003 Employer Account Ft. Collins Market Cmployerkame: VlneyTruddnd (G'CM) Phone: (970)493-1403 Phys Address: 2607 Brookhlp Rd Mall Address: 2607 Brockh6l Rd CIO, ate, Zp: F64 Collins, 00 805241015 City, State, Zip: Fon Colpne, 00 OM41015 Primary Contact Kevin Wney SIC Code Employer Tax to: Contact Phone: (970) 4934403 E11t: r—i suspense Employer i[`� Print Dmgztoro Contact Fax: (970)493•6263 r IS Employer Subscriber r Print RX Contact Role: Primary Coateol �r COD Required Employer Notes: K6VN1 WILY Coll 070-218-178S second contact Carole Vlney Auto CommuniciWan Definition C M1 Farm eon Mewed 29II{0ai WIC Injury Canoallodrtws Employer No Show ImU Po>; Kahn alley W/L Inlwy Well a RWA EmplOyal Paaem Vleh R Far, Kean Way WIC Injury IOW a Raare hdwyAaMiy Stsors Re{ Fax Khan Viny NWrjwy rnW al a Rare NaMnJuy AcWky SLAW: In KoAn Vkwy W/O I*y MON a RWM Padent Rebnel Report Fax Kevin Way WIC lf4UFy Jf1QWaRadf ROMWAPp01nlmenlR Felt K4vin Mny Ij lwanchlo Notes Association Name; Plnnscal Assurance PO Box 469013 Denver, CO 802450013 Notes: Association Noma: Stephan KrachtMD PO BOX25903 Ovenand Perk, KS 6BZ256903 Notes: Association Name: Way Trucking 2607 Braakhlll Rd Fart Collins, CO (103241016 Notes: rj"1 omPlayerleOount 0sad00ten ml Vonmet Mall Contact 'Snnay Trueldnd ,Kle_11m0 Nneyvydklnpmrten.ronl ,Number 07040d203 7Aney TNddne 67a4so-an3 VryTruwna NnrylnrdArp®men.mn 47We3A20 •Vlny Trucid-0 Wneylruddrrpdbnen.00m 070.400.0209 'Vlny Truddna veroWu"9W8AAM ar049&62W 'An"Tmoklrp Vin"MtA g*rrsncom 67042M263 Pays 1 of 4 AA/EEO Employer 0 Iwo 4019 Canonrn dpwlna awpernlen AA Rgne Rerenad. APR-26-2013 12:01 96% I Print Onto: W2612013 Revision Date: %f2612012 P.002 APR-25-2013 12:05 OCCUPATIONAL HEALTH 970 297 6599 P.004 Employar Nams: "Trucking (CCM) Phys Address: 2607 emolditu Rd Employer Account Ft, Collins Market Phone: (070) 493.1403 Mall Address; . 2607 Brockhlll Rd City, State, Zip: Fort Collins, CO 006241015 City, State, Zip: Fort Collins, CO 606241015 Em Mir Relp"one: j Viney Trucking Vlnay Trualdrg Vlney Truciting Loatlon Lea0w Location Billing Address: 2607 Brookhil Ro Fad Co01ne CO SOS241015 Pdmery Contact: Kevin many Billing (injury): Kevin Vinsy Billing (Non Injury); Kevin Vlney Contact Phone: (070)493-1403 Ext Contact Phone; (970)493.1403 Ext Centaet Phone: (070)493.1403 Contact I = (970)49M283 Contact Fax: (970)49,W63 Contact Fax: (970)493.8253 QXt: Contact Role: Primary Contact Canteet Role: Primary Contact Contact Role: Primary Contact Pinnacel Assdranoo Pinnacal A24uratice Plnnacol Assurance WIC Insurance Caller WIC Insuranca Carriar W/C Insurance Career Billing Addimf:' Primary CnnoaoC WIC Clabna Billing (Injury), WIC Claims Billing Mon Injury); W/C Claims Contact Phone: (800)33R-7811 Fat: Content Phons: (800)332.7611 Eat Contact Pho". (900)332.7611 Contact Fax: (303)790-7226 Contact Fax: (303)790.7220 Contact Fax: (303)790.7220 F'xt- Conteet Rolo: Workers Camp Clalma Contact Role; Workers Comp Chime Contact Role; Workers Comp Claims Staphon Kracht MD Stephen Kraeht MD Stephen Kroeht MD Medial Review OMtsr Medical Review Officer Medical Review Weer BOIIng Addreaa: Primary Contact Stephan KrWt MO lallling pnjury)i 6lephan Knecht MD Billing (Non Injury): Stephen Krarht MD Contact Phona: (88"2.2281 Ext Contact Phone: (888)382.2281 Eft Correct Phone; (888)382-2281 Contact Far. (913)480.4029 . Contact Fax: (013)469.4029 Contact Fax: (913)489.4029 Fxt Contact Rae: MRO Contact Conteot Role: MRO Canted Contact Rola: MRO Comm Service Package: DOT Physical PrePiaeement Employer Admin Noun: ;a. Component, DOT Physical PrePtacement Bill To: Employer Way Trucking Phone (970)493-1403 Fax (970)493-M r mr amployercount APR-25 7 ,�01312:01 S80.6o Page 2 of 4 AA/EEO Employer O IM •2011 Cehrawa CDMvIMe C9WAWn AN Rphd Ibrna4 96: Print Dots: 04125I2013 Revision Data: 07/25/2012 P1003 APR-25-2013 12:05' OCCUPATIONAL HEALTH 970 297 6599 P.005 Employer Account Ft. Collins Market Employer hl,i6w Vhley Trucking (OW) Phone; (970)493.1403 Pi0's Addrirj6- +(;; 2607 131`001(h9l Rd � Mall Address• 2607 Brookh9l Rd City, State, ZIp yu Fort Conne, CO 908241015 City, Sete, 23p: Pon Colllns, 00 805241015 Service PacJmge: DOT Physical Recertification Employer AdminNotoe:'` I L COmponerda . COT Physical RacedifIcallon I $60.50 Bf11 To: Employer Way Trucking Photo (970)493-1403 Fax (970)423.OM Seivtce P,pc6ge: Reg UOS collect & BAT Post Accident Employer Admin No� w 7: i 1•, icy]. I component:." BrosthAlcoholTmtPost Accident $3150 8111 To: Employer VlneyTnko¢Ing ' ? Phone (970)493•1403 Fax (970)4934M ComponaM Regu4ted UDS Callao Poet Accident $31.00 � Bill To: Employer r Viney Trucift . '.,,. Phone (970)493-1403 Fax (970)493-0293 +ce , �'r I r-mr amploy{e'&COUrit Page 3 of AAICHO Employar IPdnt Data: 04"r2013 O 1k0e .ptacenorix4 ow»hwc«vanw,NinbwMnnd. Revision Date: o7r2512012 APR-25+13 12t01 96i