HomeMy WebLinkAbout114340 CUSTOM SERVICES OF COLORADO INC - INSURANCE CERTIFICATE (4)ACORD CERTIFICATE OF LIABILITY INSURANCE DATE28/2/ 4
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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).
vaooucER CONTACT
NAME: Karole Peters
Ewing -Leavitt Insurance Agency H NNu Ea; FAX
No 866.237.2178
4025 St. Cloud Dr. AODREas: karole-petersfleavitt.com
Suite 100 WSURER(S)AFFORDING COVERAGE MAIL•
Loveland, CO 80S38 INSURER A: Secura Insurance 22543
INSURED Custom Services of Colorado, Inc. INSURERB: Pinnacol Assurance 41190
PO Box 800 I��'3�-0 INSURERC:
Mead, CO 80542-0800 INSURER D:
INSURER E :
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 CONTRACTOR 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.
LTR
TYPE OF INSURANCE
INSR
WVD
POLICY NUMBER
MMIODMYYY
MMIDO
LIMITS
A
GENERAL LIABILITY
X COMMERCIAL GENERAL LIABILITY
CLAIMS -MADE T OCCUR
X Blkt Addl Insured
20-TC-0003160361-4
ON -WING OPERATIONS
03/29/2014
0312912015
EACH OCCURRENCE
$ 1,000
PREMISES Ea occurrence
E 100
MED FXP(Any we person)
$ 5,00(
PERSONAL BADVINJURY
$ Includec
X
Blkt Waiver of Sub
GENERAL AGGREGATE
$ 2,000,00
GEN'L AGGREGATE LIMIT APPLIES PER:
POLICY X jECOT- F7 LOC
PRODUCTS -COMP/OPAGG
$ 2,000,00
$
A
AUTOMOBILE LIABILITY
X ANY AUTO
ALL OWNED SCHEDULED
AUTOS AUTOS
X HIRED AUTOS X NON -OWNED
AUTOS
20-A-003160362-4
03/29/2014
03MO15
Es accident
E 1,000,00(
BODILY INJURY (Per person)
$
BODILY INJURY (Per Sodden)
$
Per accident)
A
X
UMBRELLA LIAR
EXCESS UAB
X
OCCUR
CLAIMS -MADE
20-CU-003160363-
03129/2014 03129/2015
EACH OCCURRENCE
$ 1,000,00
AGGREGATE
$ 1,000,00
DIED I X I RETENTION$ 10.00
$
B
WORKERS COMPENSATION
AND EMPLOYERS' LIABILITY
ANY PROPRIETORIPARTNERIEXECUTIVC�
OFFICERIMEMSER EXCLUDED?
(Mandatory In NH)
If descnbe under
DESCRIPTION OF OPERATIONS below
NIA
4025555 01/01/2014 01/01/2015 X TORY MITS ER
BLANKET WAIVE E.L. EACH ACCIDENT
OF SUBROGATOO E.L. DISEASE -EA EMPLOYEEE
E.L. DISEASE -POLICY LIMIT
$ 1'000'00
1 000
$ 1 00D 00
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Atboh ACORD 101, Additional Remarks Schedule,, If more space is requlred)
ity of Ft. Collins is shown as additional insured as respects General Liability
CERTIFICATE HOLDER CANCELLATION
City of Ft. Collins
2S6 W. Mountain Avenue
P. 0. Box 580
Ft., 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 .J
t71989-2010 ACORD CORPORATION. All rights reserved.
ACORD 25 (2010105) The ACORD name and logo are registered marks of ACORD