HomeMy WebLinkAbout303367 CLEAN ENERGY - INSURANCE CERTIFICATE (6)CLEAN-1 OP ID: RG
.ft O CERTIFICATE OF LIABILITY INSURANCE
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DAM 111/9/2014
11/19/2014
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
Dodge Insurance Services Inc.
DBA: Arroyo Insurance Services
3510 Torrance Blvd., Suite 305
Torrance, CA 90503
AG
CAN 7 Rosemary GOmeZMASTER
PHONE FAX
ac Na Ea,310-356-8201 uc Na: 310-316-1825-
E-MAIL
ADDRESS: rosemaryg@arroyoins.com
INSURERS AFFORDING COVERAGE
NAIL M
Neil S. Dodge
INSURERA: Federal Insurance Co
20281
INSURED Clean Energy, A CA Corp.
4675 MacArthur Court, Ste #800
Newport Beach, CA 92660
INSURER B: National Union Fire of PA
19445
INSURERC: Pacific Indemnity Co.
20346
INSURER D :
NSURERE:
NSURER F
COVERAGES CERTIFICATE NUMBER- REVIS!ONN lMlcoo.
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.
TR
TYPE OF INSURANCE
OL
UB
POLICY NUMBER
(MMIDDPOLICYEFFIYYYYI
I IMPOWUMPI
LIMITS
A
X
COMMERCIAL GENERAL LIABILITY
CLAIMS -MADE Fx1OCCUR
Ded BUPD $100000
35816898
11/30/2014
11/30/2015
EACH OCCURRENCE
$ 1,000,00
PREMISES Ea occu ante
$ 1,000,00
X
MED EXP (Any one person)
$ 10,00
PERSONAL &ADV INJURY
$ 1,000,00
AGGREGATE LIMIT APPLIES PER:
POLICY � PE0 LOG
GENERAL AGGREGATE
$ 2,000,00
GEN'L
X
PRODUCTS - COMP/OP AGO
$ 2,000,00
$
OTHER:
A
AUTOMOBILE
LIABILITY
ANYAUTO
73521989
11/30/2014
11/30/2015
COM
Ea acdNEtlBID SINGLE LIMIT
ent
$ 1,000,00
X
BODILY INJURY (Per person)
$
ALL OWNED SCHEDULED
AUTOS AUTOS
X
BODILY INJURY Peraaitlent
( )
$
X NON -OWNED
HIRED AUTOS AUTOS
X
PROPERTY DAMAGE
Per accident
$
Auto Liab Ded
$ 5,00
"
A
X
UMBRELLA LIAR
EXCESS LIAR
X
OCCUR
CLAIMS -MADE
79860791
11/30/2014
11/30/2015
EACH OCCURRENCE
$ 6,000,00
X
AGGREGATE
$ 6,000,00
DED I X I RETENTION$ none
$
C
WORKERS COMPENSATION
AND EMPLOYERS' LIABILITY YIN
ANY
OFFICER/MEMBOEREXCLNER/E ECUTIVE N
NIA
71736418
11/30/2014
11/30/2015
PER OTH-
X STATUTE ER
E.L. EACH ACCIDENT
$ 1,000,00
E.L. DISEASE - EA EMPLOYEE
$ 1,000,00
(Mandatory In NH)
B vas, deunbe under
DESCRIPTION OF OPERATIONS belm
E.L. DISEASE - POLICY LIMIT
$ 1,000,00
B
Excess Liability
BR64196618
11/30/2014
11/30/2015
EachOcc 8,000,00
Retention $10,000
Aggregate 8,000,00
DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Ramarks Schedule, may be attached N more space Is requhad)
RE: Site #590-Trans Fort/Ft. Collins - 117 N. Mason, Fort Collins, CO 80524
TRAN000
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
Trans Fort THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
Ft Collins City's Director of ACCORDANCE WITH THE POLICY PROVISIONS.
Purchasing & Risk Management AUTHORIZED REPRESENTATIVE
For N. Mason 5_
Fort Collins, CO 80524
V 1UBB-2014 ACORD CORPORATION. All rights reserved.
ACORD 25 (2014/01) The ACORD name and logo are registered marks of ACORD