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HomeMy WebLinkAboutROBERTS EXCAVATION CORPORATION - INSURANCE CERTIFICATE (9)ROBER-7 OP ID: CERTIFICATE OF LIABILITY INSURANCE 1 DATE 04/01114 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 PRODUCER Phone:970-482-7747 Lindsay Cral O Brown & Brown Inc Fax: 970.484-4165 PHONE ,970-4B2-7747 1 F9 No: 970-48"165 4532 Boardwalk Dr, Suite 200 Fort Collins, CO 80525 pODREss: lcral bbcolorado.com Sharma M Jamsay INSURE S AFFORDING COVERAGE MAC S INSURER A: WeatReld Insurance Company 24112 INSURED Roberts Excavation Corporation INSURER B: Pinnacol Assurance Company 41190 Attn: Gerald Roberts INSURER C: 1801 1 st Street Berthoud, CO 80513 INSURERD: 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. IEFF TR TYPE OF INSURANCE POLICY NUMBER MMID Y MMIO EXp Y LIMITS A GENERAL LIABILITY X COMMERCIALGENERAL LIABILITY CLAIMS -MADE FK OCCUR TRA7548279 04/01H4 04/01/16 EACH OCCURRENCE $ 1,000,00 PR MI ES Eaoccurerlce S 500,000 MEDEXP(Any amPartisan) S 10, PERSONAL B ADV INJURY B 1,000,000 GENERAL AGGREGATE S 2,000,00( GEN'L AGGREGATE LIMIT APPLIES PER: '- LOC POLICY X IFCT PRODUCTS -COMPIOP AGG S Z000'00( $ A AUTOMOBILE LIABILITY X ANY AUTO ALL OWNED SCHEDULED AUTOS AUTOS NON -OWNED HIRED AUTOS AUTOS X ProD TRA7548279 W01/14 04/01/15 COMBINED SINGLE LIMIT a aWdent 100000( BODILY INJURY (Per Person) $ BODILY INJURY (Par accident) S PROPERTY DAMAGE PareaNaM S $ A X UMBRELLA LIAR EXCESS UA9 X OCCUR CLAIMS -MADE TRA7648279 04/01/14 04/01/15 EACH OCCURRENCE S 2,000,00 AGGREGATE S 2,000,00 OED I X I RETENTION 0 S B WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANY PROPRIETORIPARTNER/EXECUTIVEYI❑N OFFICERIMEMBER EXCLUDED? (Mandatory In NH) If y deson"under DESCRIPTION OF OPERATIONS D M NIA 3241433 06/01/13 06/01114 X WCSTATULIM - OTH• ER E.L.EACH ACCIDENT $ 1,000,00 E.L. DISEASE - EA EMPLOYEE S 1,000,0 E.L. DISEASE - POLICY LIMIT $ 1,000, A Leased/Rented Eq TRA7548279 04101114 04/01/15 Lsd/Rntd 500,OK Ded 1,00 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Aead1 ACORD 101, AddNlonal Ramada, Schedule, N mM apace Is required) Fax# 221-6707 CERTIFICATE HOLDER CANCELLATION CITYF10 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 215 N. Mason St. AUTHORIZED REPRESENTATIVE Fort Collins, CO 80521 ©1988.2010 ACORD CORPORATION. All rights reserved. ACORD 25 (2010105) The ACORD name and logo are registered marks of ACORD NOTEPAD RO INSURED'3 NAME Roberta Excavation Corporation ID: 1C OP D: rho following apply if required by written contract: orcial General Liability ket Additional Insured - Ongoing Operations - Form CG3229 0610 kat Additional Insured - Completed Operations - Form CG7133 0211 ary 6 Non -Contributory Coverage - Form CG7143 1112 ket Waiver of Subrogation - Form CG7143 1112 Project Aggregate - Form CG2503 0509 Location Aggregate - Form CG2504A 0509 cial Automobile: t Additional Insured - Form CA7078 0911 t Waiver of Subrogation - Form CA0444 0111 ss Auto Expanded Endorsement - CA 7078 0312 y s Non -Contributory Coverage - Form CA 7075 1008 Compensation: Waiver of Subrogation - Form 359b is following form. PAGE 2 DATE 04/01/14 ROBER-7 OP ID: CERTIFICATE OF LIABILITY INSURANCE OAT03131O/YYYYI 03/31114 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: 970-482-77 3rown & Brown Inc Fax: 970�84�1 1532 Boardwalk Dr, Suite 200 :on Collins, CO 80525 3hanna M Jamsay INSURER A: INSURED Roberts Excavation Corporation Attn: Gerald Roberts 1801 1 st Street Berthoud, CO 80513 COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: ifj 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. INS LTR TYPE OFINBURANCE POLICY NUMBER MMID Y OFF EXP MN LOST$ A GENERAL L111BI1JrY X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE I OCCUR CWP7548279 04/01/14 04/01/15 EACH OCCURRENCE $ 1,000,0 PREMISE Ea occ n nnc $ 500,00 MED EXP (Any one person) $ 10,0001 PERSONAL S ADV INJURY $ 1,000, GENERAL AGGREGATE S 2r000, GENT AGGREGATE LIMIT APPLIES PER: POLICY X PRO- LOD PRODUCTS-COMP/OP AGG S 2,000,00( $ A AUTOMOBILE LIABILITY ANY AUTO ALL OWNED SCHEDULED AUTOS AUTOS HIRED AUTOS NON -OWNED AUTOS Pro Dm CVVP7548M 04/01M4 O4/01/15 COMBINED SINGLE LIMIT Es accident)r 1 000 , X BODILY INJURY (Per person) S BODILY INJURY (Par accident) $ PROPERTY DAMAGE Paraccidenl $ X $ A X UMBRELLA LIAR EXCESS LIAO X OCCUR CLAIMS -MADE CWP7548279 04/01/14 04/01/15 EACH OCCURRENCE B 2,000,00 AGGREGATE $ 2,000,001 OEO I X I RETENTIONS 0 S B WORKERS COMPENSATION AND EMPLOYERS' LIABILITYTORY ANY PROPRIETORIPARTNER/EXECUINE YIN OFFICER/MEMBER EXCLUOEDP © (Mandatory In NH) It ea, cesuibo under DESCRIPTION OF OPERATIONS below NIA 3241433 06/01/13 D6/01/14 X WC STATIT OTH- LIMITS E.L. EACH ACCIDENT $ 1,000,00 E.L. DISEASE -EA EMPLOYEES 1,D0D,DD E.L. DISEASE- POLICY LIMIT s 1,000,0 A Leased/Rented Eq CWP7648279 04/01/14 04/01/15 Lsd/Rntd 600,000 Ded 1,00 DESCRIPTION OF OPERATIONS LOCATIONS/ VEHICLES (Attach ACORD 101, Additional Remerka Schedule, If more apace Is required) Fax# 221-6707 CERTIFICATE HOLDER CANCELLATION CITYF10 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 215 N. Mason St. AUTHORIZED REPRESENTA`.TIIVyVE�,� Fort Collins, CO 80521 ACORD 26 (2010/05) C 1988-2010 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD NOTEPAD RO WW1RE0'S NAME Roberts Excavation Corporation ID: IC OP D: The following apply if required by written contract: arcial General Liability ket Additional Insured - Ongoing Operations - Form CG3229 0610 ket Additional Insured - Completed Operations - Form CG7133 0211 ary i Non -Contributory Coverage - Form CG7143 1112 ket Waiver of Subrogation - Form CG7143 1112 Project Aggregate - Form CG2503 0509 Location Aggregate - Form CG2504A 0509 al Automobile: Additional Insured - Form CA7078 0911 Waiver of Subrogation - Form CA0444 0111 Auto Expanded Endorsement - CA 7078 0312 6 Non -Contributory Coverage - Form CA 7075 1008 Compensation: Waiver of Subrogation - Form 359b is following form. PAGE 2 DATE 03/31/14