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HomeMy WebLinkAboutBACKFLOW SOLUTIONS INC - CONTRACT - RFP - 7598 BACKFLOW PREVENTION PROGRAM MANAGEMETNDocuSign Envelope ID: E2CF8AFB-C748-4F60-A472-55776F270DF9 DocuSign Envelope ID: E2CF8AFB-C748-4F60-A472-55776F270DF9 DocuSign Envelope ID: E2CF8AFB-C748-4F60-A472-55776F270DF9 DocuSign Envelope ID: E2CF8AFB-C748-4F60-A472-55776F270DF9 DocuSign Envelope ID: E2CF8AFB-C748-4F60-A472-55776F270DF9 DocuSign Envelope ID: E2CF8AFB-C748-4F60-A472-55776F270DF9 DocuSign Envelope ID: E2CF8AFB-C748-4F60-A472-55776F270DF9 DocuSign Envelope ID: E2CF8AFB-C748-4F60-A472-55776F270DF9 5/7/2014 DocuSign Envelope ID: E2CF8AFB-C748-4F60-A472-55776F270DF9 DocuSign Envelope ID: E2CF8AFB-C748-4F60-A472-55776F270DF9 DocuSign Envelope ID: E2CF8AFB-C748-4F60-A472-55776F270DF9 DocuSign Envelope ID: E2CF8AFB-C748-4F60-A472-55776F270DF9 DocuSign Envelope ID: E2CF8AFB-C748-4F60-A472-55776F270DF9 DocuSign Envelope ID: E2CF8AFB-C748-4F60-A472-55776F270DF9 DocuSign Envelope ID: E2CF8AFB-C748-4F60-A472-55776F270DF9 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. INSURER(S) AFFORDING COVERAGE INSURER F : INSURER E : INSURER D : INSURER C : INSURER B : INSURER A : NAIC # NAME: CONTACT (A/C, No): FAX E-MAIL ADDRESS: PRODUCER (A/C, No, Ext): PHONE INSURED COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: 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). 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. OTHER: (Per accident) (Ea accident) $ $ N / A SUBR WVD ADDL INSD 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. $ $ $ PROPERTY DAMAGE $ BODILY INJURY (Per accident) BODILY INJURY (Per person) COMBINED SINGLE LIMIT AUTOS AUTOS AUTOS NON-OWNED HIRED AUTOS ALL OWNED SCHEDULED ANY AUTO AUTOMOBILE LIABILITY Y / N WORKERS COMPENSATION AND EMPLOYERS' LIABILITY OFFICER/MEMBER EXCLUDED? (Mandatory in NH) DESCRIPTION OF OPERATIONS below If yes, describe under ANY PROPRIETOR/PARTNER/EXECUTIVE $ $ $ E.L. DISEASE - POLICY LIMIT E.L. DISEASE - EA EMPLOYEE E.L. EACH ACCIDENT ER OTH- STATUTE PER (MM/DD/YYYY) LIMITS POLICY EXP (MM/DD/YYYY) POLICY EFF LTR TYPE OF INSURANCE POLICY NUMBER INSR DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) EXCESS LIAB UMBRELLA LIAB EACH OCCURRENCE $ AGGREGATE $ $ OCCUR CLAIMS-MADE DED RETENTION $ PRODUCTS - COMP/OP AGG $ GENERAL AGGREGATE $ PERSONAL & ADV INJURY $ MED EXP (Any one person) $ EACH OCCURRENCE $ DAMAGE TO RENTED PREMISES (Ea occurrence) $ COMMERCIAL GENERAL LIABILITY CLAIMS-MADE OCCUR GEN'L AGGREGATE LIMIT APPLIES PER: POLICY PRO- JECT LOC CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DD/YYYY) CANCELLATION AUTHORIZED REPRESENTATIVE ACORD 25 (2013/04) © 1988-2013 ACORD CORPORATION. All rights reserved. CERTIFICATE HOLDER The ACORD name and logo are registered marks of ACORD $ $ 1900 E. Golf Road DSP Insurance Services, Inc. Cert ID 14353 PO Box 580 Westfield Insurance Company 24112 Technology Insurance Company 42376 Westchester Surplus Lines Ins. 10172 5/2/2014 12607 S. Laramie Ave. TRA5061356 1/1/2014 1/1/2015 A PROF/POLL LIABILITY Suite 650 N TRA5061356 1/1/2014 1/1/2015 A A B C X X X X J Stephen Pohl Schaumburg IL 60173 Fort Collins CO 80522 Alsip IL 60803 (847) 934-6100 (708) 389-5600 (847) 934-6186 X X X X X 1,000,000 300,000 1,000,000 1,000,000 1,000,000 5,000,000 5,000,000 10,000 2,000,000 TRA5061356 1/1/2014 1/1/2015 TWC3305722 1/1/2014 1/1/2015 1,000,000 1,000,000 2,000,000 2,000,000 City of Fort Collins Attn: Norman Mill City of Fort Collins is added as Additional Insured with respect to General Liability and Automobile Liability as required by written contract. Backflow Solutions, Inc. Each Claim/ Aggregate G24352705001 1/1/2014 1/1/2015 Page 1 of 1 DocuSign Envelope ID: E2CF8AFB-C748-4F60-A472-55776F270DF9