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Home My WebLink AboutEVANS TRUCKING LLC - INSURANCE CERTIFICATE (4)05-31-3535839-2 Shelter Mutual Insurance Company ***MANUAL DEC*** 1817 W Broadway Columbia, MO 65218 1-800-SHELTER (743-5837) General Liability Insurance Policy Declarations Named Insured: BRUCE R EVANS Policy Number: 05-31-3535839-2 6490 N COUNTY ROAD 3 Effective Date: 08/29/2014 (12:01 A.M. CST) FORT COLLINS CO 80524-9304 Expiration Date: 08/29/2015 (12:01 A.M. CST) Notice to the Mortgagee/Loss Payee/Add] Insured: Your interest will be continuous until cancellation notice is mailed to you. These Declarations are part of your policy and replace all prior Declarations. Business of the Named Insured: HAULS DIRT/ROCK Agent: BRUCE JOHNSON AGENCY INC 05-5549-10 PO BOX 270663 FORT COLLINS CO 80527 970-226-5034 The Named Insured is a(n): Audit Period: Limits of Insurance General Aggregate (Other Than Products — Completed Operations) $2,000,000 Products — Completed Operations Aggregate Limit (See Each Classification Below) Included Personal And Advertising Injury Limit $1,000,000 Each Occurrence Limit $1,000,000 Rented To You Limit $100,000 Medical Expense Limit $5,000 Individual Annually Any One Premises Any One Person 99793 TRUCKERS PAYROLL PER $1000 $176.00 INCLUDING PRODUCTS &/OR COMPLETED OPERATIONS $25,200 ITEM ZIP CODE: 80524 PREMISES & OPERATIONS- 88801 PREMIUM CHARGE FOR REINSURANCE OF $500,000 $938.00 OCCURRENCE, EXCESS OF $500,000 OCCURRENCE. ITEM ZIP CODE: 80524 6490 N COUNTY ROAD 3 FORT COLLINS CO Premium Adjusting Endorsements Limas =-=Deductible --T4,-4�Number = 'Premium Additional Insured - Owners, Lessees or Contractors - CG 20 10 04 13 $18.00 Scheduled Person or Organization MARTIN MARIETTA MATERIALS Additional Insured - Owners, Lessees or Contractors - CG 20 10 04 13 $18.00 Scheduled Person or Organization BIVENS TRUCKING AND EXCAVATING Additional Insured - Owners, Lessees or Contractors - CG 20 10 04 13 $18.00 Scheduled Person or Organization CONNELL RESOURCES INC Additional Insured - Owners, Lessees or Contractors - CG 20 10 04 13 $18.00 Scheduled Person or Organization CITY OF FORT COLLINS JJ Page 1 05-31-3535839-2 Total for Term (This is Not a Bill): $1,186.00 Commercial General Liability Coverage Form CG 00 01 04 13 Excl Damage To Work By Subcontr On Your Behalf CG 22 94 10 01 Fungi Or Bacteria Exclusion CG 21 67 12 04 Total Pollution Exclusion Endorsement CG 2149 09 99 Exclusion - Exterior Insulation And Finish Systems CG 21 86 12 04 Mutual Policy Notification 5-18-5 Colorado Changes - Civil Union IL O1 25 11 13 Amendatory Endorsement G-252.1-G Non -Binding Arbitration CG 24 01 12 04 Employment -Related Practices Exclusion CG 21 47 12 07 Exclusion - Access Or Disclosure Of Information CG 21 07 05 14 Lead Poisoning Exclusion Endorsement B-601-B Colorado Changes - Cancellation And Nonrenewal IL 02 28 09 07 Nuclear Energy Liability Exclusion Endorsement (Broad Form) IL 00 21 05 02 Limitation Of Coverage To Designated Premises Or Projects Described Premises CG 2144 07 98 Common MARTIN MARIETTA MATERIALS 2710 WYCLIFF RD RALEIGH NC 27607-3033 CITY OF FORT COLLINS PO BOX 580 FORT COLLINS CO 80522-0580 (For Office Use Only) Transaction: RNEW B H.O. CODE: 1,186.00 Policy ID: 66004218766 Policy Term: One Year G-2.10-G IL00171198 BIVENS TRUCKING AND EXCAVATING 862 W WILLOX LN FORT COLLINS CO 80524-1147 CONNELL RESOURCES INC 5150 SE FRONTAGE RD FORT COLLINS CO 80528-9526 Date Issued: 07-15-2014 '06172014' End of Declarations II Page 2