HomeMy WebLinkAbout188139 DOHN CONSTRUCTION INC - INSURANCE CERTIFICATE (2)UP IU: KC
, lu. R CERTIFICATE OF LIABILITY INSURANCE D09/26ATE /2 V3
�.� 09/26/2013
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: 970-635-940C
PFS Insurance Group -JT Fax: 970-635-9401
4848 Thompson Pkwy, Ste 200
Johnstown, CO 80534
INSURED Dohn Construction, Inc. p INSURER A: Employers Mutual
DCI Residential, LLC P a00 (3� INSURER 9: Pinnacol Assurance 41190
2642 Midpoint Drive
INauRERc:
Fort Collins, CO 80525
INSURER D :
INSURERS:
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.
ILTR
TYPE OFIN8UIfANCE
POLICY NUMBER
M1IDDNYYY
MMIDWYYYY
LIMA
A
GENERAL LIABILITY
X COMMERCIAL GENERAL LIABILITY
CLAIMS -MADE X OCCUR
Blanket Add'l Ins
1 R57255
10/01/2013
10/01/2014
EACH OCCURRENCE
3 1,000,00
PREMISES Ea occurrence
It 100,00
MED EXP (Any one Person)
$ 5,00
PERSONAL SADVINJURY
$ 1,000,09
X
Blanket Waiver
GENERAL AGGREGATE
S 2,000,00
GEWL AGGREGATE LIMIT APPLIES PER:
POLICY X PRO LOC
PRODUCTS-COMP/OP AGG
S 2,000,00
$
A
AUTOMOBILE
LIABILITY
ANY AUTO
ALL OWNED AUTOS
SCHEDULED AUTOS
HIRED AUTOS
NON -OWNED AUTOS
1Z57255
10/01/2013
10/01/2014
COMBINED SINGLE LIMIT
accident)
$ 1,000,00(
X
INJURY
BODILY NJURY (Per person)
BODILY
E
BODILY INJURY (Per accident)
It
PROPERTY DAMAGE
(Per accident)
$
X
X
$
$
A
X
UMBRBLLALIAO
EXCESS LAB
X
OCCUR
CLAIMS -MADE
1J57255
10/01/2013
10/01/2014
EACH OCCURRENCE
$ 10,000,00
AGGREGATE
$ 10,000,09
DEDUCTIBLE
RETENTION $
E
$
B
WORKERS COMPENSATION
AND EMPLOYERS' LIABILITY
ANY PROPRIETORIPARTNER,EXECUTIVE YIN
OFFICER/MEMBER EXCLUDED?
(Mandatory in NH)
If yes desmbe unde
DESCRIPTION OF OrPERATIONS below
N/A
3055407
07/01/2013
07/01/2014
X VJC S1TAaTU- OTH-
E.L. EACH ACCIDENT
$ 1,000,00
E.L. DISEASE - EA EMPLOYEE
$ 1,000,00(
E.L. DISEASE -POLICY LIMIT
$ 1,000,00
A
Builders Risk
1X57255
10/01/2013
10/01/2014
One Loc. 5,000,00
All Loc 5,000,00
DESCRIPTION OF OPERATIONS I LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if mom space is required)
RE: Poudre Fire Authority Facilities in Fort Collins. If required by written
contract or written agreement the following provisions apply subject to the
policy terms, conditions, limitations and exclusions: The Certificate Holder
is included as Additional Insured for ongoing and completed operations under
General Liability.
CFRTIFICATF HOI nFR CANCELLATION
CITYFC
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
City of Fort Collins
Financial Services
AUTHORIZED REPRESENTATIVE
Purchasing Division
215 N. Mason St. 2nd Floor
Fort Collins CO 80524
ACORD 25 (2009/09)
01988-2009 ACORD CORPORATION. All rights reserved.
The ACORD name and logo are registered marks of ACORD