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HomeMy WebLinkAbout131163 ADECCO INC & ITS SUBSIDIARIES - INSURANCE CERTIFICATE (3)ACORN® CERTIFICATE OF LIABILITY INSURANCE `/- DATE(MMDDYYYY) 12f292014 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($), 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 endomement(s). PRODUCER Marsh USA, Inc. 1166 Avenue of the Americas CONTACT NAME: , FAX PHONE pIC No: LAIC_No,EML E-MAIL ADDRESS: New York, NY 10036 Attn: Adecco.certs@Marsh.com Fax: 212-948-0018 INSURERS AFFORDING COVERAGE NAIC M INSURER A: AXA Insurance Company 33022 370044-ALL-GAUWG75-16 NO INSURED Adecco Inc. 8 its subsidiaries 10151 Deerwood Park Blvd. INSURER B: WA WA INSURER C: Insurance Company Of The State Of PA 19429 INSURER D: NIA NIA Building 200 Jacksonville, FL 32256 INSURER E : INSURER F : COVERAGES CERTIFICATE NUMBER: NYC-006685059-04 REVISION NUMBER:I 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 TYPE OF INSURANCE ADOL UBR POLICY NUMBER EFF MMn)DPOUCY/YYYY POLICY UP MMIDD/YYYY LIMITS A GENERAL LIABILITY X COMMERCIAL GENERAL LIABILITY 71 CLAIMS -MADE 1_X I OCCUR PCS002071(15) 01/01/2015 01/0112016 EACH OCCURRENCE $ 2,000,000 RAMA R NTED PREMISES Ea occurtence $ 2000000 MED EXP JAny we rson) $ 5,000 PERSONAL S ADV INJURY $ 2,000,000 GENERAL AGGREGATE $ 4,000,000 GEN'L AGGREGATE LIMIT'ECE APPLIES PER: X POLICY X PRO- X LOC PRODUCTS - COMP/OP AGG $ 4,000,000 $ AUTOMOBILE LIABILITY ANY AUTO ALL OWNED SCHEDULED AUTOS AUTOS NON OWNED HIRED AUTOS HAUTOS COMBINED SINGLE LIMIT Ea accicern BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ PROPERTY DAMAGE Per accident $ $ UMBRELLA LAB EXCESS LIAR OCCUR CLAIMS -MADE EACH OCCURRENCE $ AGGREGATE $ DED RETENTION $ 1 $ C C C WORKERS COMPENSATION ANDEMPLOYERS'LIABILITY YIN ANY PROPRIETORMARTNER/EXECUTIVE ❑ OFFICERIMEMBER EXCLUDED? N (Mandatory in NH) If yes. describe ender DESCRIPTION OF OPERATIONS below NIA 024508528(ADS) 024508532 () CA 024508533 FL () OV01/2015 01/01/2015 01/0112015 0110112016 01101/2016 01101/2016 X I vvCSTATIU oTH- E L EACH ACCIDENT 2,000,000 $ E.L. DISEASE - EA EMPLOYE $ 2,000,000 E.L. DISEASE - POLICY LIMIT 2,D00,000 1 $ DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101. Additional Remarks schedule, It more space Is required) Branch Location: ADeoco Engineering 8 Technical, 300 E. Boardwalk, Fon Collins, CO 80525. CFRTICIr:ATF k4n1 nCR CANCELLATION City of Fort Collin SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Attn: Ed Bonnede THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 215 N. Mason St ACCORDANCE WITH THE POLICY PROVISIONS. Fart Collins, CO 80524 AUTHORIZED REPRESENTATIVE of Marsh USA Inc. / Jason Clarice 01988.2010 ACORD CORPORATION. All rights reserved. ACORD 25 (2010/05) The ACORD name and logo are registered marks of ACORD AGENCY CUSTOMER ID: 370044 LOC #: New York ADDITIONAL REMARKS SCHEDULE Page 2 of 2 AGENCY NAMED INSURED Marsh USA, Inc. Ade Inc. 8 its subsldiiui s 10151 Deenlood Park Blvd. Building 200 POLICY NUMBER Jacksonville, FL 32256 CARRIER NAIC CODE EFFECTIVE DATE: THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, FORM NUMBER: 25 FORM TITLE: Certificate of Liability Insul WORKERS COMP CONTINUED: POLICY NUMBER: 024506531 STATE: AK,AZ,VA EFFECTIVE: 111/2015-11112016 PAPER: INSURANCE COMPANY OF THE STATE OF PA CARRIER. AIG POLICY NUMBER: 024508529 STATE: IL,KY,NC,NH,UT,VT EFFECTIVE: 11112015-1I12016 PAPER: INSURANCE COMPANY OF THE STATE OF PA CARRIER: AIG POLICY NUMBER: 024508534 STATE: ME EFFECTIVE: 1/12015-1I12016 PAPER: INSURANCE COMPANY OF THE STATE OF PA CARRIER: AIG POLICY NUMBER: 024508536 STATE: MA, NO, WA, WI, WY EFFECTIVE: 1/1I2015-1/12016 PAPER: INSURANCE COMPANY OF THE STATE OF PA CARRIER: AIG POLICY NUMBER: 024508530 STATE: NJ, PA EFFECTIVE: 1/112015-1/112016 PAPER: INSURANCE COMPANY OF THE STATE OF PA CARRIER: AIG POLICY NUMBER: 024508535 STATE:MN EFFECTIVE: 111/2015-1112016 PAPER THE INSURANCE COMPANY OF THE STATE OF PA CARRIER: AIG EXCESS WORKERS COMP-OHIO ONLY'. INSURER: NATIONAL INSURANCE COMPANY OF THE STATE OF PA POLICY NUMBER: 9883942 EFFECTIVE DATE: 1/112015 EXPIRATION DATE: 1112016 LIMITS: SIR:$3,D00,000 EL EACH ACCIDENT: $1,000,000 EL DISEASE: $1,000,000 EL DISEASE - EACH EMPLOYEE: $1,000,000 Ind /9nnamn © 2008 ACORD CORPORATION. All rights The ACORD name and logo are registered marks of ACORD ACORO ® CERTIFICATE OF LIABILITY INSURANCE DATE 2014 YYY). 12R9Y1014 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 Marsh USA, Inc. 1166 Avenue of the Americas New York, NY 10036 Attn: Adecco.certs@Marsh.mm Fax: 212-94HO18 CONTACT NAME: PHONE FAX UVC No ExtIArc No ADE-MAIL DRESS: INSURER(ST AFFORDING COVERAGE NAIC a INSURER A: AXA Insurance Company 33022 370044-ALL-GAUWC-15-16 NO INSURED Adecco Inc. 8 its subsidiaries 10151 Deerwood Pads Blvd. Building 200 Jacksonville, FL 32256 INSURER B: National Union Fire Insurance Cc Of Pittsburgh 19445 INSURER c: Insurance Company 01 The State 01 PA 19429 1 INSURER D : NIA WA INSURER E INSURER F nnvcowr_cc CERTIFICATE NUMBER: NYC-008885060-04 REVISION NUMBER:I v 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, EXCLUSIONSAND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR LT TYPE OF INSURANCE ADDL UBR NUMBER POLICPOLICY MMDDYIWYY MM/DD/YYYY LIMITS A GENERAL LIABILITY X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE MOCCUR PCS002071(15) 0110112015 01M12016 EACH OCCURRENCE $ 2,000,000 AMA T REN PREMISES Eao rrence $ 2,000,000 MED EXP(My one person) $ 5,000 PERSONAL a ADV INJURY $ 2,000,000 GENERAL AGGREGATE $ 4,000,000 GEN'L AGGREGATE % POLICY LIMIT APPLIES PER X PRO- M LOC PRODUCTS - COMP/OP AGG $ 4,000,000 $ B B AUTOMOBILE LIABILITY ANY AUTO ALL OWNED SCHEDULED AUTOS AUTOS NON -OWNED HIRED AUTOS AUTOS I 5874044 (ADS) 5874046(MA) 0110112015 01/0112015 0110112016 01/0112016 COMBINED SINGLE LIMIT Ea ecciciont 2.000,000 BODILY INJURY(Per person) S BODILY INJURY(Per accdnt) $ PROPERTY DAMAGE PeramxleniB $ A % UMBRELLA LIAB EXCESS UAB X OCCUR CLAIMS -MADE XS002072(15) 0110112015 0110112016 EACH OCCURRENCE $ 5,000,000 AGGREGATE $ 5,000,00o DED % RETENTION$ 10.000 $ C C C WORN ERSCOMPENSATION ANDEMPLOYERS'LIABILITY ANY PROPRIETORIPARTNERIEXECUTIVE Y/N OFFICERJMEMBER EXCLUDED? (Mandatory in NH) I/ yes, describe under DESCRIPTION OF OPERATIONS below NIA 024508528(ADS) 024508532 CA ( ) 024508533 FL) ( 0110112015 01101/2015 0110112015 0110112016 01/01/2016 0110112016 WCSTATu- DTM- ITCH LIMITS FR E.L. EACH ACCIDENT $ 2,000,000 E.L. DISEASE -EA EMPLOYE $ 2,000,000 E.L. DISEASE -POLICY LIMIT $ 2,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS / VEHICLES (Arrach ACORD 101, Additional Rem. s Schedule, if mom spec. le m wnmi) Branch Location: Adecco Engineering 8 Technical, 4025 Automation Way F1, Fart Collins, CD 80525, CFRTtorATE HOLDER CANCFI I ATION City of Fort Collin SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Attn: Ed Bonnede THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 215 N. Mason St ACCORDANCE WITH THE POLICY PROVISIONS. Fort Collins, CO 80522 AUTHORIZED REPRESENTATIVE of Mann USA Inc. Jason Clarke rJc.s �f2_ © 1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25 (2010105) The ACORD name and logo are registered marks of ACORD AGENCY CUSTOMER ID: 370044 LOC #: New York ,acoRo® ADDITIONAL REMARKS SCHEDULE L_ � Page 2 of 2 AGENCY NAMED INSURED Marsh USA, Inc. Adecco Inc. & its subsidiaries 10151 Deelwood Park Blvd. Building 200 POLICY NUMBER Jacksonville, FL 32256 CARRIER NAIC CODE EFFECTIVE DATE: THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, FORM NUMBER: 25 FORM TITLE: Certificate Of Liability Insurance WORKERS COMP CONTINUED: POLICY NUMBER: 024508531 STATE: AK,AZ,VA EFFECTIVE: 11112015- 1/112016 _ PAPER: INSURANCE COMPANY OF THE STATE OF PA CARRIER: AID POLICY NUMBER: 024508529 STATE: IL,KY,NC,NH, UT,VT EFFECTIVE: 1/112015-1/112016 PAPER: INSURANCE COMPANY OF THE STATE OF PA CARRIER: AIG POLICY NUMBER: 024508534 STATE: ME EFFECTIVE: 111/2015-1112016 PAPER: INSURANCE COMPANY OF THE STATE OF PA CARRIER: AIG POLICY NUMBER: 024508536 STATE: MA, NO, WA, WI, WY EFFECTIVE: 111/2015-111/2016 PAPER: INSURANCE COMPANY OF THE STATE OF PA CARRIER: AIG POLICY NUMBER: 024508530 STATE: NJ, PA EFFECTIVE: 1112015- 1112016 PAPER: INSURANCE COMPANY OF THE STATE OF PA CARRIER: AIG POLICY NUMBER: 024508535 STATE: MN EFFECTIVE: 111/2015-1112016 PAPER. THE INSURANCE COMPANY OF THE STATE OF PA CARRIER: AIG EXCESS WORKERS COMP-OHIO ONLY: INSURER: NATIONAL INSURANCE COMPANY OF THE STATE OF PA POLICY NUMBER: 9883942 EFFECTIVE DATE: 1/12015 EXPIRATION DATE: 1/12016 LIMITS: SIR: $3,000,000 EL EACH ACCIDENT: $1,000,000 EL DISEASE: $1,000,000 EL DISEASE - EACH EMPLOYEE: $1,000,000 101120081011 © 2008 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD aco o® CERTIFICATE OF LIABILITY INSURANCE th-�' °"�/2DD11<°°""" THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER Marsh USA, Inc. 1166 Avenue of the Amemas New York, NY 10036 Attn: Adecco.ceds@Marsh.com Fu: 212-948-0018 CONTACT NAME: PHONE FAX LAIC No. Exti, IMC No E-MAIL ADDRESS: INSURERS AFFORDING COVERAGE NAIC$ INSURER A: AXA Insurance Company 33022 370044-ALL-GAUWC-15-16 NO INSURED Adecco Inc. 8 its subsidiaries 10151 Deerwood Park Blvd. Building 200 Jacksonville, FL 32256 INSURER B: WA WA INSURER CsuInsurance Company Of The State Of PA 19429 INSURER D : WA WA INSURER E INSURER F: COU1011A7c H MBER NvC-MABASn5R.R4 - RFVISION NUMBER' 1 c.vrr_r.ww ..�.. .. _..._.._...__... _______. 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 TYPE OF INSURANCE AD I. UBR POLICY NUMBER POLICY EFF IMMIDDfYYYY1 POLICY EXP IMMfDOfYYYY) LIMITS A GENERAL LIABILITY PCS002071(15) 01/01/2015 01/01/2016 EACH OCCURRENCE $ 2,000,000 AMA ET RENTED PREMISES Ea occurrence $ p,ggg ggg X COMMERCIAL GENERAL LIABILITY MED EXP (Any one person) $ 5,000 CLAIMS,NNDE M OCCUR PERSONAL B ADV INJURY $ 2,000,000 GENERAL AGGREGATE $ 4.000,000 GENL AGGREGATE LIMIT APPLIES PER: PRODUCTS -COMP/OP AGG $ 4,D00,000 s X POLICY X PRO- X IFCT LOC SINGLE LIMIT OMOBILE LIABILITY Ee a.dni BODILY INJURY (Per Person) $ ANY AUTO BODILY INJURY (Per a¢ident) $ ALL OWNED SCHEDULED AUTOS AUTOS NON -OWNED HIRED AUTOS AUTOS R PROPERTY DAMAGE Per accident $ UMBRELLA LIAB OCCUR EACHOCCURRENCE $ AGGREGATE $ EXCESS UAB CLAIMS44ADE DEC) I I RETENTION$ $ O WORKERS COMPENSATION 024508528(ADS) 01/01/2015 01/01/2016 WCSTATU- OTH- D C ANDEMPLOYERTLIABILITY ANY PROPRIETORIPARTNER/EXECUTIVE YIN OFFICEWMEMBER EXCLUDED? ❑N (Mandatory in NH) If yes desalbe under DESCRIPTION OF OPERATIONS babe N /A 024508532 CA ( ) 024508533 (FL) 01/01/2015 011012015 01101/201(1 01N12016 E.L. EACH ACCIDENT 2,000,000 $ E.L. DISEASE - EA EMPLOYE $ 2,000,000 E.L. DISEASE - POLICY LIMIT 2,000,000 $ DESCRIPTION OF OPERATIONS LOCATIONS I VEHICLES (Attach ACORD for, Additional RamA&S Schedule, If more spa's M required) Branch Location: Adeccn Staffing, 3711 JFK Parkway, Suite 305, Fort Collins, CO 80525. City of Fort Collins Alin: Ed Bonnefte 215 N. Mason St. Fort Collins, CO 80524 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORU:ED REPRESENTATIVE of March USA Inc. Jason Clarke 3 f&_ ACORD CORPORATION. All rights reserved. ACORD 25 (2010/05) The ACORD name and logo are registered marks of ACORD AGENCY CUSTOMER ID: 370044 LOC #: New York ACOREY ADDITIONAL REMARKS SCHEDULE L- i Page 2 of 2 AGENCY NAMED INSURED Marsh USA, Inc. ADecco Inc. & its sulDsidianes 10151 Deenwood Park Blvd. Building 200 POLICY NUMBER Jacksonville, FL 32256 CARRIER NAIC CODE EFFECTIVE DATE: ADDITIONAL REMARKS THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, FORM NUMBER: 25 FORM TITLE: Certificate of Liability Insurance WORKERS COMP CONTINUED, POLICY NUMBER: 024508531 STATE: AKAZ,VA EFFECTIVE: 11112015- 1/12016 PAPER: INSURANCE COMPANY OF THE STATE OF PA CARRIER: AID POLICY NUMBER: 024508529 STATE: IL,KY,NC, NH,UT,Vr EFFECTIVE: 111/2015- 1112016 PAPER: INSURANCE COMPANY OF THE STATE OF PA CARRIER: AIG POLICY NUMBER: 024508534 STATE: ME EFFECTIVE: 1/112015-1 00% PAPER: INSURANCE COMPANY OF THE STATE OF PA CARRIER: AIG POLICY NUMBER: 024508536 STATE: MA, ND, WA, WI, WY EFFECTIVE: 11112015-11112016 PAPER: INSURANCE COMPANY OF THE STATE OF PA CARRIER: AIG POLICY NUMBER: 02450a530 STATE: NJ, PA EFFECTIVE: 1112015-1112016 PAPER: INSURANCE COMPANY OF THE STATE OF PA CARRIER: AIG POLICY NUMBER: 024508535 STATE:MN EFFECTIVE: 11112015-1/112016 PAPER: THE INSURANCE COMPANY OF THE STATE OF PA CARRIER: AIG EXCESS WORKERS COMP-OHIO ONLY: INSURER: NATIONAL INSURANCE COMPANY OF THE STATE OF PA POLICY NUMBER: 9883942 EFFECTIVE DATE: 1/12015 EXPIRATION DATE: 1112016 LIMITS: SIR: E3,OD0,000 EL EACH ACCIDENT: $1,000,000 EL DISEASE: $1,000,000 EL DISEASE- EACH EMPLOYEE: E1,DOD,000 ACORD 101 (2008101) © 2008 ACORD CORPORATION. All rights reserved The ACORD name and logo are registered marks of ACORD ACORO® CERTIFICATE OF LIABILITY INSURANCE Lam" °; 714 °"YY°) 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: H 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 Marsh USA, Inc. 1166 Avenue of the Americas CONTACT NAME: PHONE FAX Arc No : E-MAIL ADDRESS: New Yak, NY 10036 Attn: Adetco.certs@Marsh.mm Fax: 212-948-0018 INSURERS AFFORDING COVERAGE NAIC s INSURERA: AXA Insurance Company 33022 370044-ALL-GAUWGI5-16 NO INSURED Adec o Inc. 8 its subsidiaries 10151 Deenvood Palk Blvd. INSURER B: National Union Fire Insurance Co Of Pittsburgh 19445 INSURER c : Insurance Company IN The Slate Of PA 19429 INSURER D : National Union Fire Ins. Co. Building 200 Jacksonville, FL 32256 INSURER E : INSURER F : COVERAGES CERTIFICATE NUMBER: NYC-006676075-04 REVISION NUMBER:1 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 OF INSURANCE ADDLITYPE INSR SUER wyn POLICY NUMBER EFF MM/DDY/YYYY MOUC M/DDYY EXP LIMITS A GENERAL ABILITY X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE M OCCUR PCS002071(15) 01/0112015 01/0112016 EACH OCCURRENCE $ 2,000,000 DAMA E TO RENTED PREMISES Ea occurrence $ 2,000,000 MED EXP (Any we person) $ 5,000 PERSONAL B ADV INJURY $ 2,000,000 GENERAL AGGREGATE $ 4,000,000 GENT AGGREGATE LIMIT APPLIES PER: X POLICY X PRO- M LOC PRODUCTS - COMPIOP AGG S 4,000,000 $ B B AUTOMOBILE UABILITY X ANY AUTO ALL OWNED SCHEDULED AUTOS AUTOS NONOWNED HIRED AUTOS HAUTOS X 5874044(ADS) 5874046(MA) 01/01/2015 01/01/2015 01101/2016 01101/2016 COMBINED SINGLE LIMIT Ea accident 2,000.000 BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ PROPERTY DAMAGE Per accident $ $ UMBRELLA LIAB EXCESS LIAR OCCUR CLAIMS -MADE EACH OCCURRENCE $ AGGREGATE $ DED RETENTION $ $ C C D WORKERS COMPENSATION ANOEMPLOYERS' ANY PROPRIETOR/PTY RIPARTNERIFJ(ECUTIVE YIN AeIU OFFICER/MEMBER EXCLUDED? � (Mandatory in NH) It yes desaihe urWer DESCRIPTION OF OPERATIONS tel NIA 024508528(ADS) 024508532 CA () FL ( ) 0110112015 01/0115 /20024508533 01101/2015 01/0112016 01101 016 01101/2016 X I WC STATU- OTH- ITO Y LIMITS; ER E.LEACH ACCIDENT . 2,000,000 S E. L. DISEASE -EA EMPLOYE $ 2,000,000 E L DISEASE -POLICY LIMIT 2,000,000 $ D CRIME WITH THIRD PARTY COVERAGE 01-841-80-05 01/01/2014 04/01/2015 LIMIT 10,000,000 $51W$15M DESCRIPTION OF OPERATIONSI LOCATIONS I VENICLES (Attach ACORD 101. Additional Remarks, Schedule, if more apace Is rac ulmd) Branch Location: Adecco Engineering 8 Technical, 300 E. Boardvialk, Fort Collins, CO 80525. CFRTIFICATF Hn1 nFR CANCELLATION City of Fort Collins SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Am: Ed. Bonneffe THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 215 N. Mason St. ACCORDANCE WITH THE POLICY PROVISIONS. Fort Collins, CO 80522 AUTHORIZED REPRESENTATIVE of Marsh USA Inc. �e Jason Clarke rJts ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25 (2010105) The ACORD name and logo are registered marks of ACORD AGENCY CUSTOMER ID: 370044 LOC #: New York ADDITIONAL REMARKS SCHEDULE Page 2 of 2 AGENCY NAMED INSURED Marsh USA, Inc. Adi= Inc. 8 its subsidiades 10151 Deenwad Park BIVd. Buikli0g 200 POLICY NUMBER Jacksonville, FL 32256 CARRIER NAIC CODE EFFECTIVE DATE: THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, FORM NUMBER: 25 FORM TITLE: Certificate of Liability Insul WORKERS COMP CONTINUED: POLICY NUMBER: 024508531 STATE: AK,AZ,VA EFFECTIVE: 11112015- 1/112016 PAPER: INSURANCE COMPANY OF THE STATE OF PA CARRIER: AS POLICY NUMBER: 024508529 STATE: IL,KY, NC,N H,UT,VT EFFECTIVE: 11112015-1/112016 PAPER'. INSURANCE COMPANY OF THE STATE OF PA CARRIER: AIG POLICY NUMBER: 024508534 STATE:ME EFFECTIVE: 1/112015-111/2016 PAPER: INSURANCE COMPANY OF THE STATE OF PA CARRIER: AIG POLICY NUMBER: 024508536 STATE: MA, NO, WA, WI, WY EFFECTIVE: 111/2015- 111/2016 PAPER: INSURANCE COMPANY OF THE STATE OF PA CARRIER: AIG POLICY NUMBER: 024508530 STATE:NJ,PA EFFECTIVE: 11112015-11112016 PAPER: INSURANCE COMPANY OF THE STATE OF PA CARRIER: AIG POLICY NUMBER: 024508535 STATE: MN EFFECTIVE: 111/2015-11112016 PAPER: THE INSURANCE COMPANY OF THE STATE OF PA CARRIER: AIG EXCESS WORKERS COMP-OHIO ONLY: INSURER: NATIONAL INSURANCE COMPANY OF THE STATE OF PA POLICY NUMBER: 9883942 EFFECTIVE DATE: 1/12015 EXPIRATION DATE: 1/112016 LIMITS: SIR:$3,000,000 EL EACH ACCIDENT. $1,000,000 EL DISEASE: $1.000,000 EL DISEASE - EACH EMPLOYEE: $1,000,000 I.rJ T-T.�nz��nnT:mcn The ACORD name and logo are registered marks of ACORD All riahts reserved.