HomeMy WebLinkAboutTIMOTHY M KEOHANE - INSURANCE CERTIFICATE (2)0ON
Erie
Insurance
100 Erie Ins. PI • Erie, PA 16530
CERTIFICATE OF INSURANCE
- THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY -
CERTIFICATE HOLDER COPY
NAME AND NUMBER OF AGENCY
DATE ISSUED 01 / 18/2014
KELLY FAMILY INSURANCE AGY INC NN 1037
NAME AND ADDRESS OF CERTIFICATE HOLDER
196 S. MAIN STREET
NAPLES . NY 14512-950e 585-374-9320
NAME AND ADDRESS OF NAMED INSURED
CITY OF FORT COLLINS
TIMOTHY M KEOHANE *
117 N MASON ST
PO BOX 662
FORT COLLINGS CO 80524-
NAPLES NY 14512-0662
This is to certify that policies, as indicated by Policy Number below, are in force for the Named Insured at the time that the certificate is being issued.
TYPE OF INSURANCE
POfJCY NUMBER i
Pot W:�Y
EFFECTIYE.DATE;
EkFffikTlOKt#ATE
UNITS OF INSURANCE
_
GE' NERAL LIABILITY
0267220068
102/22/2014
02/22/2015
EACH OCCURRENCE
Is 3/0O(onn
COMMERCIAL GENERAL LIABILITY
FIRE DAMAGE
$
OCCURRENCE FORM
GEN'L AGGREGATE LIMIT APPLIES
(Any one premises)
300000
PER: POLICY
MED EXP (Any one person)
$ 5000
PERSONAL & ADV INJURY
$ 300000
GENERALAGGREGATE
$ 600000
PRODUCTS-COMP/OP AGG
$ 600000
BODILY INJURY
S
(EACH PERSON)
BODILY INJURY
$
EACH ACCIDENT)
PROPERTY DAMAGE
$
BODILY INJURY AND
S
PROPERTY DAMAGE'
COMBINED
EACH OCCURRENCE
AGGREGATE
WORKERS COMPENSATION
0867200103
02/22/2014
02/22/2015
STATUTORY
BODILY ACCIDENT $ EACH ACCIDENT
100000
AND
EMPLOYERS LIABILITY
INJURY DISEASE $
00000 POLICY LIMIT
BY DISEASE S 100000 EACH EMPLOYEE
DESCRIPTION OF OPERATIONS/LOCATIONSNEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS
CANCELLATION: SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIHA I IUN UA I E I HEHtuI-, NU I lUt WILL bt
DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS.
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).
THIS CERTIFICATE IS ISSUED FOR INFORMATION PURPOSES ONLY AND
CONFERS NO RIGHTS ON THE CERTIFICATE HOLDER. IT DOES NOT
AFFIRMATIVELY OR NEGATIVELY LIST, AMEND, EXTEND OR OTHERWISE
ALTER THE TERMS, EXCLUSIONS AND CONDITIONS OF INSURANCE
COVERAGE CONTAINED IN THE POLICY(IES) INDICATED ABOVE. THE TERMS
AND CONDITIONS OF THE POLICY(IES) GOVERN THE INSURANCE COVERAGE
AS APPLIED TO ANY GIVEN SITUATION. LIMITS SHOWN MAY HAVE BEEN
REDUCED BY CLAIMS PAID. THIS CERTIFICATE OF INSURANCE DOES NOT
CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED
ERIE INSURANCE
SEE REVERSE SIDE
OF-1568 09112 CIF
AUTHORIZED
REPRESENTATIVE
COMPLETE NAME AND ADDRESS OF CERTIFICATE HOLDER OR ADDITIONAL INSURED
CITY OF FORT COLLINS
1 17 N MASON ST
FORT COLLINGS CO 80524