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Home My WebLink About541354 COATING SPECIALISTS LLC - INSURANCE CERTIFICATEAUP 9Q 9014 Q-41AM WACfprn 6rnUn inr - CO Springs No.2935NTIJ 1 OP ID: DocuSig�n-Envelope ID: 6303DAC5`-6rK-49I3'r'r AT�44OOC �IABILI'NSURANCE vA 1 r DATE(aNNDNM) PRODUCER 08/29/2014 Western Group Inc. -Pueblo Phone: 7W54T3604 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION 511 W 10th St Ste A ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE P,O. Box 1958 HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OF Pueblo, CO 81002 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW Paul Sinatra INSURERS AFFORDING COVERAGE NAIC # INSURED Coating Specialist, LLC 6340 Sayres Rd INSURER A, LANDMARK AMERICAN INSURANCE CO Colorado Springs, CO 80927 INSURER a: National Casualty Co. INSURER THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED AROVE FOR T ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SURdECTTO ALL TH POLICIES, AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSft AD POUCYEFTT:cnve pOLICYEXPR POLICY NUMBER GENERAL UABIUW A X X COhW.ERCIALGENER^ALUIABILITY LHA137662 06119/2014 O6/19/2( CLAIMS MADE q OCCUR LIMIT AUTOMOBILE LIABILITY C X ANYAUTO ALL OWNED AUTOS X SCHEDULEDAUTOS X HIRED AUTOS X NON-OWNEDA(Jr06 ANY AUTO EXCESSI UMBRELLA LIABam B X X OGGVR ClA1MS MADE DEDUCTIBLE X RETENTION S 1000t WORKERS COMPENSATION AND EMPLOy,,, LIABILITY ANY PROPRIETORIpARTNERIEXECUTIVR Y❑ OFFICERIMEM9ER EXCLUDED? (MAndatory in NH) RYee, dewdbe under SPECIAL PROM IONS bekw. OTNER 07/03/2014 1 07/03/20 06/19/2014 1 06/19/201 DESCRIPTION OF OpEMTIONS I LOCATK)NS I VEHICLES I EXCLUSIONS ADDED W ENDORSEMENT I SPECVLL PROVISIONS Painting- Steel Structures or Bridges The City of Fort Collins are included as Additional Insured as respects of General Liability and Auto Liability Policies, subject to the terms, conditions and exclusions of the policies. 303 484-5899 Project name; Timberline & Mulberry Bridge CERTIFICATE HOLnPR City of Fort Collins Director of Purchasing and Risk Managment PO box 680 Fort Collins, CO 80552 ACORD 25 (2009101) IE POLICY PERIOD INDICATED. NOTWITHSTANDING r0 WHICH THIS CERTIFICATE MAY BE ISSUED OR `TERMS, EXCLUSIONS AND CONDITIONS OF SUCH ATON LIMITS EACH OCCURRENCE S 11000, 15 PREMISE a S 100,00 MEDEXP( Ol peran S 6,00 PERSONAL&ADVINJURY i 1.000,00 GENERAL AGGREGATE 3 ,2,000,DO PRODUCTS - COMPIOPAGG S 2,000, 16 COMBINED SINGLE LIMIT (Ea ecade.A) S 1,000,90 BODILY INJURY S (PER PERSON) (PER ACCIDENY)S AGR (PER 6 ACCIDENT) AUTO ONLY -EA ACCIDENT 6. OTHERTWTN EAACC S AUTO ONLY. 'AGG $ $ 4,000,00 EACHOCCURRENCE 5 AGGREGATE S 4,o0D,O0 6 f WC STATLL OTH- S R.L EACH ACCIDENT S E.L. DISEASE, EAEWLOYE S E.L. DISEASE -POLICY LIMIT i SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE C ELL RETHEExPIRATION DATE THEREOF, THE ISSIIINO.NOS6RER VALL TO O Y9 WRITTEN NOTICE TO THE CERmflCA, IIOLDE2l NAME TH FT,B rW RE DP 60 SHALL IMPOSE No OBUOATON OR LIAaI IV N 6 ITS AGENTS OR REPRESENTATIVES. I AIfTHORREb REPRESENTATNEPauI Sinatra The ACORD name and logo are registered marks 009ACACORD CORPORATION. All rights reserved, Anc 9Q 901A 0.41AM Wncfcrn frnun inr - CO Springs No.2935kTI.e. 2 OPID•LJ )ocuSign Envelope ID: 6303DAC5-63FA-4963-B1F7-1851968440F5 - - IMPORTANT If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be. endorsed. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). 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). DISCLAIMER This Certificate of Insurance does not constitute a contract between the issuing insurer(s), authorized representative or producer, and the certificate holder, nor does it affirmatively or negatively amend, extend or alter the coverage afforded by the policies listed thereon. ACORD 25 Auc 90 9 n I A Q•A1AM W P f f A r n Grniin T n r - CO Springs DocuSign Envelope ID: 6303DAC5-63FA-4963-BiF7-185196a440F5 No.2935 P. 3 PINNAA COL ASSURANCE INSURED: Coating Specialist LLC 6340 Sayres Road Colorado Springs, CO 80927 ENDORSEMENT: Waiver Of Subrogation 7501 E Lowry Blvd Denver, CO 80230.7008 Phone; (303) 361-40001(800) 873-7242 Fax: (303) 391-50001(88B) 329-2251 NCCI #: WC000313 Policy #: 4124367 AGENT: Western Group, Inc - Colorado SpAn 2860 S. Circle Dr Suite 150 Colorado Springs, CO 80906 (719)448-9609 We have the right to recover our payments from anyone liable for an injury covered by this policy. We will not enforce our right against the person or organization named in the Schedule. (This agreement applies only to the extent that you perform work under a written contract that requires you to obtain this agreement from us.) This agreement shall not operate directly or indirectly to benefit anyone not named in the Schedule. SCHEDULE City of Fort Collins Director of Purchasing and Risk Managment PO Box 580 Fort Collins, CO 80552 Effective Date: August 29, 2014 Expires on July 1, 2015 Pinnacol Assurance has issued this endorsement August 29, 2014. Matt McKenzie Underwriter R""'cd AimniM. • 7501E Lw B.Yd • 06ever, Co 60230 Pepe 1 er J P,N�,N�, 08/V2014NZ?y.13 4124367 r1V4a1eC 02pdr2007 MIR Ga 90 901d Q•A9AM WPctPrn Crnon n Envelope ID: 6303DAC5-63FA-4963-B1F7-185196844OF5 A ORD Pinnace] Assurance 7501 E Lowry Blvd Denver, CO 80230-7006 6340 Sayras Road Colorado Springs, CO 80927 COVERAGES T n r — C0 Springs CERTIFICATE OF ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCI MAY PERTAIN. THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HERE I,YSR I AOOL :ML LLLNIfM1' %YIERCML C-0iFlWL W Akrrf CIAIMaM OCCUR Lmr-AaPL1 PER TgamenE MAennr AMAVrO KIOrmEDNrtOS scNEnulEOAvrca VEREO AMres IgNgYNED AVM AAC[MFBIIrY Au✓AOrb occurs U cLnus L1ACE eEOMOn6LE RETENnCH s VrOPKens COMPEN6AnON µ0 A EMPLO Erta LRlury .R. rRarR�RmsnTeq'yE�curnE DFnCFWEOABy{IXaUD�} n y.•. dwn uaayr N:Ma sPECNi EarnnsgNs LMnn City of Fort Collins Director of Purchasing and Risk Managment PO Box 580 Fort Collins, CO 80552 4124367 No.2935 P. 4 LIABILITY INSURANCE °^ oeMmDrr 013 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. INSURERS AFFORDING COVERAGE NAIC$ INsurrEan: Pinneeol Assurance 41190 EuuREA e: wEarsaLc: rhuRER o: INSWiER E; 2ED NAMEO ABOVE MMENT WITH RESPECT IN IS SUBJECT TO FOR THE POLICY TO WHICH THIS ALL THE TERMS, EXCLUSIONS PERIOD INDICATED. N5TWI7HSTANDNG CERTIFICATE MAYBE ISSUED OR AND CONDITIONS OF SUCH Po YEf4LGTlvE f yEaFi rR, LNTE PATE LMR9 EKHOCI'IFR£XCE 0. QETORE R -'A s MEO PERsoN4La nw eMVtr e 6aALAIXwE TE PRcoUcrs.mwropnDa DDL,eacgsnlnELAvr Aca4m aCdLYiNIMV BWLY UMMRY �dDAI FPOPERIY ' . ONIKiE IPLeatlaNl AVrO CNIY•EA AOppENT OTNEP TIWr FAACC N N0my: EaC11 OLaxm4+CE AaaREr,T,TE 1vc eIATU OTNEA LJ 07/01R014 07/01/2015 TmrLuvr; Ei EepIADaDENr "Moo' EL DIsS E IEPLOYEE Wm ' ELDWASE Pace LRUT MW rfSPEOwL PROVISIONS CANCELLATION SHOULDANY OF THE EXPIRATION MAIL' 10 DAYS WRITTEN LEFT, BUT FAILURE LIABILITY OF ANY REPRESENTATIVES. THE ABOVE DESCRIBED DATE THEREOF, THE NOTICE TO THE TO MAIL SUCH NOTICE FOND UPON THE COMPANY. POLICIES BE CANCELLED BEFORE ISSUING COMPANY WILL ENDEAVOR TO CERTIFICATE HOLDER NAMED TO THE SHALL IMPOSE NO OBLIGATION OR ITS AGENTS OR AUTHORIZED REPRESENTATIVE Matt McKenzie Underwriter ACORn rnRPn9A1fnM .sae AuP 9Q 9014 Q A)AM WACfprn Grnon inr — CO Springs No.2935 P. 5 DocuSign Envelope ID: 6303DAC5-63FA-4963-BiF7-1851968440F5 CERTIFICATE HOLDER COPY City of Fort Collins Director of Purchasing and Risk Managment PO Box 580 Fort Collins, CO 80552 IMPORTANT If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). 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). DISCLAIMER The Certificate of Insurance on the reverse side of this form does not constitute a contract holder, nor does it affirmatively or negatively amend, extend or alter the coverage between the issuing insurer(s), authorized representative or producer, and the certificate afforded by the policies listed thereon.