HomeMy WebLinkAbout128575 GRAY OIL CO INC - INSURANCE CERTIFICATE (2)GRAYO-1 OP ID: JK
FI-
sl►coRO CERTIFICATE OF LIABILITY INSURANCE DATE0
09128/228/2013
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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 Phone: 303-674-8685 NAM1, Jeff Kahns
Association Ins. Marketing Inc PHONE
P.O. Box 631610 Fax: 303-674-8819 uc No Em;303 674 8685
Highlands Ranch, CO 80163 EroIL... Ikahns0aimco
INSURED Gray Oil Co Inc J7J
804 Denver Ave iR 'Z(�
Fort Lupton, CO 80621
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 I
TYPE OF INSURANCE
kDDL
POUCYNUMBER
IYYWTs
A
GENERAL LABILITY
X COMMERCIAL GENERAL LIABILITY
CLAIMS -MADE E71 OCCUR
3042366
I
10/0112013
10/01/2014
EACH OCCURRENCE
S 1,000,00
PREMISES Es occurrence
S 100,00
S 5,000
S 1,000,00
t 2,000,00
S 2,000,00
MED EXP (Any arse -person)
PERSONAL SADV INJURY
GENERAL AGGREGATE
GEWL AGGREGATE
X POUCY
UMn APPLIES PER
PRO- LOC
PRODUCTS-COMP/OP AGO
A
ABTOMO6aE UABLITY
X ANY AUTO
A�0. OWNED SCHEDULEDAUTOS
NON-0VMED
HIREDAUTOSqXAUTOS
X MCS-90 BRNO POLL
3042366
10M1/2013
10MI12014
CCIMBINS
Ee acatlera L M
1,000,00
s
i
f
- —
B ULYIWURY(Per Pawn)
BODILY INJURY (PeraGd"Do
Paramtlam�M
=
A
X
UIORELIA WY
EXCESSLMB
ODOUR
CLAIM&MADE
3042US
1010112013
10/0112014
EACHOCCURRENCE
S 5,000,00(
AGGREGATE
$ 5,000,
CEO I I RETENTION
S
WORKERS COMPENSATION
AND EMPLOYERS' LIABILITY
B I ANY PROPRIETORIPARTNER/EXECUTWEYO
OFFICER/MEMBER EXCLUDED?
(MantlMory In NH)
If yes describe under
DESCRIPTION OF OPERATIONS WI.
NIA
1350372
02101/2013
02M1/2014
X WCSTA U-
TORY
E. EACH ACCIDENT
S 1r000r�
E.L OI6EASE-EAEMPLOYE
s 1r000,
E.L. DISEASE -POLICY LIMIT
I S 1000'wc
DESCRIPTION OF OPERATIONS I LOCATIONS / VEHICLES (Asses ACORD 101, AOetlonsl Remarks Schemse, ff man apes is required)
City of Fort Collins
PO Box 580
Fort Collins, CO 80522-0580
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
ACORD CORPORATION. All rights reserved
ACORD 25 (2010105) The ACORD name and logo are registered marks of ACORD