HomeMy WebLinkAbout114340 CUSTOM SERVICES OF COLORADO INC - INSURANCE CERTIFICATE (5)ACORD CERTIFICATE OF LIABILITY INSURANCE DATE09/2014
M Ol/09/2014
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 CONTACT
_NAME: Karole Peters
Ewing -Leavitt Insurance Agency PHHONo�;970.679.7355 AC r1o:866.Z37.2178
4025 St. Cloud Dr. ADDRESS; karole-peters@leavitt.coin
Suite 100 INSUREll AFFORDMIG COVERAGE MARS
Loveland, CO 80338 _ INSURER A: Secura Insurance 22S43
INSURED Custom Services of Colorado Inc. INSURERB: Pinnacol Assurance 41190
1\I,0"PO Box 800 INSUMRC:
Mead, CO 80542-0800 INSURER D:
INSURER F
rnvclaer.cs rr PTIFIrATP NtIMRFR' 14-15 WC Renewal 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.
LTR
TYPE OF INSURANCE
INSR
WVD
POLICY NUMBER
MMID
MMIW
LIMA
A
GENERAL LIABILITY
X COMMERCIAL GENERAL LIABILITY
CLAIMS -MADE a OCCUR
X 81 kt Addl Insured
20-TC-0003160361-3
03/29/2013
03/29/2014
EACH OCCURRENCE
$ 1,000,000
PREMISES Es ocwmence
S 100, 00
MED EXP (Any om, person)
$ 5 00
PERSONAL SADV INJURY
$ Incl ude
X
B1kt Waiver of Sub
GENERAL AGGREGATE
$ 2,000,00
GEN'L AGGREGATE LIMIT APPLIES PER:
17 POLICY X JMECT LOC
PRODUCTS-COMP/OP AGG
$ 2 000,00
S
A
AUTOMOBILE DABB.RY
X ANY AUTO
ALL OWNED SCHEDULED
AUTOS AUTOS
X HIRED AUTOS X NON -OWNED
20-A-003160362-
09129/2013.
0312912014
Es accident
S 1,000 00
BODILY INJURY (Per person)
$
BODILY INIURY(Per accident)
$
Per accident
S
S
A
X
UMBRELLA LAB
EXCESS LAB
X
OCCUR
CLAIMS -MADE
20-CU-003160363-210312912013
03/29/2014
EACH OCCURRENCE
$ I,000,00
AGGREGATE
S 1,000,00
DED I X I RETENTIONS 10,00
$
B
WORKERS COMPENSATION
AND EMPLOYERS' LIABILITY YIN
ANY PROPRIETOR/PARTNER/EXECUTwy--I
OFFICEWMEMBER EXCLUDED? LJ
(Mands"In NH)
If yyes, describe under
I DESCRIPTIONOFOPERATIONS "I"
NIA
4025555i 0110112014
BLANKET WAIVER'
OF SUBROGATION
1! 01/01/2015
X TORV LIMITS ER
E.L. EACH ACCIDENT
$ I,000, 00
E.L.DISEASE-FA EN 0
$ 1,000,00
E.L. DISEASE-POLICYLIMn
S 1 000,000
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ABach ACORD 101. Additional Remarks Schedule, It more space Is required)
ity of Ft. Collins is shown as additional insured as respects General Liability
r VOTmIr ATV unl n1=0 CANr.F1 I ATIr1N
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 Ft. Collins
256 W. Mountain Avenue
AUTHORIZED REPRESENTATIVE
P. 0. Box 580
Ft. Collins, CO 80522-0580
Karole Peters KAPETE
(J 1'JO15-LU1U A6UKU UUKrumAI Iuly. All rights reserve0.
ACORD 25 (2010/05) The ACORD name and logo are registered marks of ACORD