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HomeMy WebLinkAbout103265 HAISTON OIL COMPANY INC - INSURANCE CERTIFICATE (13)OP ID: BA `611 O CERTIFICATE OF LIABILITY INSURANCE �� D08/28/2ATE Y4 o8/z8nola 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 endorsements . PRODUCER PFS Insurance Group - JT 4848 Thompson Pkwy, Ste 200 Johnstown, CO 80534 John Hintzman CONTACT NAME: PHONE FAX IAIC, No Eat, A/C No : E-MAIL ADDRESS: PRODUCER HAIST-1 CUSTOMER ID k: INSURERS AFFORDING COVERAGE NAICN INSURED Haiston Oil Company, Inc INSURER A: Acuity Insurance Co. 14184 335 S Summit View Dr INSURERS: Pinnacol Assurance Co 41190 Fort Collins, CO 80624 INSURER C INSURER D : INSURER E 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 LTR rypE OF INSURANCE UB POLICY NUMBER POLICY EFF MMIODIYYYY POLICY E%P MMIDDNYYY LIMITS A GENERAL LIABILITY X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE O OCCUR X80073 09/24/2014 09/24/2015 EACH OCCURRENCE $ 1,000,00 pRAEMISES Ea oc urrence $ 100,00 MED EXP (My one person) $ 5,00 PERSONAL $ ADV INJURY $ 1,000,00 GENERAL AGGREGATE $ 2,000,00 GEHL AGGREGATE LIMIT APPLIES PER: X POLICY ,P.- RO LOC PRODUCTS AGG S 2,000,00 S A AUTOMOBILE LIABILITY ANY AUTO ALL OWNED AUTOS SCHEDULED AUTOS HIRED AUTOS NON -OWNED AUTOS X80073 09/24/2014 09/24/2016 COMBINED SINGLE LIMIT (Ea accident) $ 1,000,00 X BODILY INJURY (Per person) $ BODILY INJURY (Per awidenp $ PROPERTY DAMAGE (PER ACCIDENT) $ X X $ A X UMBRELLA LAB EXCESS LAB IX OCCUR CLAIMS -MADE X80073 09I24I2014 09124I2015 _ EACH OCCURRENCE $ 2,000,00 AGGREGATE $ 2,000,00 DEDUCTIBLE RETENTION $ 10,000 $ X _ $ B WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANY PROPRIETORMARTNERIEXECUTIVE YIN OFFICER/MEMBER EXCLUDED' (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below____T� NIA 4169103 02/01/2014 02/01/2015 X WC STATU- OTH- RY A E.L. EACH ACCIDENT $ 500,00 E.L. DISEASE - EA EMPLOYEE $ 600,00 E.L. DISEASE -POLICY LIMIT $ 500,00 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101, Additlonal Remarks Schedule, if mom apace Is required) CITYFTC City of Fort Collins Purchasing Department 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. ©1988.2009 ACORD CORPORATION. All rights reserved. ACORD 25 (2009/09) The ACORD name and logo are registered marks of ACORD