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acoiza° CERTIFICATE OF LIABILITY INSURANCE
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DATE(MMIDDNYYY)
7/112014
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
TrueNorth
PO Box 847
Longmont, CO 80502
CONTACT
NAME:
PHONE 303 776-5122 - FAx 303 776-5495
_AfC_ do_E:J: ( ) we No : ( )
ADDRIESS:
INSURER(S) AFFORDING COVERAGE
NAIC#
INSURER A: Westfield Insurance Company
24112
INSURED
INSURER B: PInnacol Assurance Company
41190
INSURER C :
MaiCon, LLC
2744 Grinnell Drive
INSURER D :
INSURER E :
Longmont, CO 80503
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.
INSR I AD SUER POLICY EFF POLICY E%P LIMITS
LTR TYPE OF INSURANCE POLICY NUMBER MMIDDIYYYY MMIDONYYY
A
X
COMMERCIAL G ENERALLIABILITY
CLAIMS -MADE OCCUR
❑X
TRA6098651
07/01/2014
07/01/2015
EACH OCCURRENCE
D MAGE�RE
PREMISES Ea occuvence
$ 1,000,000
$ 500,000
MED EXP (Any one person)
$ 10,000
PERSONAL S ADV INJURY
$ 1,000,000
GEN'L
AGGREGATE LIMIT APPLIES PER:
POLICY [X�PRO-
LOC
OTHER:
GENERAL AGGREGATE
$ 2,000,000
PRODUCTS - COMP/OP AGG
$ 2,000,0010
Per Project Max
$ 5,000,000
A
AUTOMOBILE LIABILITY
X ANY AUTO
AU OS SCHEDULED
X HIREDAUTOS X AUAUTOS
OTOSMED
TRA6098651
07/01/2014
07/01/2015
COMBINED SINGLE LIMIT
Ea ami
$ 1,000,00
BODILY INJURY (Per person)
$
BODILY INJURY (Per accident)$
PR
PerOPERT n DAMAGE
S
$
A
X
UMBRELLA LIAR
EXCESS LIAB
X
OCCUR
CLAIMSIADE
TRA6098651
07/01/2014
07/01/2015
EACH OCCURRENCE
$ 2,000,000
AGGREGATE
$ 2,000,00
DED I X RETENTIONS 0
Is
B
WORKERS COMPENSATION
AND EMPLOYERS' LIABILITY
ANY PROPRIETORIPARTNERIEXECUTIVE VIN
OFFICERIMEMRER EXCLUDED' I
(Mandatory in NH)
DESCRIPTION OF OPERATIONS below `J
If yes, describe under
NIA
4045600
07/01/2014
O7/O1/2015
PER OTH-
X STATUTE ER
E.L. EACH ACCIDENT
$ 1,000,00
E.L. DISEAS--EA EMPLOYE.
$ 1,DDQDU
EL. DISEASE - POLICY LIMIT
$ 1,000,000
DESCRIPTION OF OPERATIONS I LOCATIONS/ VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space Is required)
City of Fort Collins
PO Box 580
Fort Collins, CO 80522
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
Tiles D'orill vti
(91988-2014 ACUKU UOKPUKA t ION. All rights reserved.
ACORD 25 (2014/01) The ACORD name and logo are registered marks of ACORD