HomeMy WebLinkAbout465554 GREYHOUND LINES INC - INSURANCE CERTIFICATE (5)A166.� �® CERTIFICATE OF LIABILITY INSURANCE
1z/zs/ola DATE2014IYYYY)
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
Arthur J. Gallagher Risk Management Services, Inc.
250 Park Avenue
3rd Floor
NAMEACT Tanya D. Stephenson
PHONE « 212-994-7085 F x q1. 212-994-7047
(AIC No
E-MAIE .Tanya_Stephenson@ajg.com
INSURERS AFFORDING COVERAGE
NAIL #
New York NY 10177
INSURER A: Insurance Company of State of PA
19429
INSURED
INSURERB:New Hampshire Insurance Company
23841
Greyhound Lines, Inc.
INSURER C:National Union Fire Ins Co Pittsbur
19445
350 N. St. Paul St.
Dallas, TX 75201
INSURER D:
INSURER E :
INSURER F:
COVERAGES CERTIFICATE NUMBER: 1434941311 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
TYPE OF INSURANCE
INBD
BR
WVD
POLICY NUMBER
POLICY EFF
MM/DDIYYYY
POLICY E%P
MMIDDIYYYY
LIMITS
A
X
COMMERCIAL GENERAL LIABILITY
GL 0949389
12/31/2014
12/31/2015
EACH OCCURRENCE
$5,000,000
CLAIMS -MADE X OCCUR
DGE TO RENTED
PREMAMAISES Eaoccumence
$5,000,000
MED EXP (Any one person)
$
PERSONAL &ADV INJURY
$5.000,000
GEN'L AGGREGATE LIMIT APPLIES PER:
GENERAL AGGREGATE
$10,000,000
POLICY 0 PRO-LOC
PRODUCTS-COMP/OP AGG
$5,000,000
$
OTHER:
C
A
C
AUTOMOBILE LIABILITY
X ANY AUTO
CA 949248 AOS
( )
CA4584447 (VA)
CA4584447 (MA)
12/31/2014
12/31/2014
12/31/2014
12/31/2015
12/31/2015
12/31/2015
COMBINED IN
Ea accident)5,000,000
$
BODILY INJURY (Per person)
S
BODILY INJURY (Per accident)
$
AUTS OWNED AUTOS
NON -OWNED
HIRED AUTOS AUTOS
PROPERTYDAMAG
Per accident
$
UMBRELLA LIAB
OCCUR
EACH OCCURRENCE
1$
AGGREGATE
$
EXCESS LIAB
CLAIMS -MADE
DED RETENTION $
1 $
B
B
B
A
B
WORKERS COMPENSATION
AND EMPLOYERS' LIABILITY YIN
ANY PROPRIETOWPARTNERIEXECUTIVE
OFFlCERIMEMeER EXCLUDED? E
(Mandatory In NH)
N / A
WC001705104(ADS)
C001705101(WI)
WC 001705095(FL)
C 001705104 (OR)
C001705104(TX)
12/31/2014
12/31/2014
12/31/2014
12/31/2014
2/31/2014
12/31/2015
12/31/2015
12/31/2015
12/31/2015
12/31/2015
X SPER TATUTE ERH
EL EACH ACCIDENT
$5.000.000
EL DISEASE -EA EMPLOYE
55,000,000
E.L. DISEASE -POLICY LIMIT
$5,000,000
B
If yes describe under
DESCRIPTION OF OPERATIONS below
C 001705099 (CA)
12/31/2014
12/31/2015
e
B
B
Workers Compensation
Workers Compensation
jWC44216118(MN)
C001178530 (MA)
1705100 (ILNO,NH,UT,VT,
12/31/2014
12/31/2014
12/31/2014
12/31/2015
12/31/2015
12/31/2015
E.L. Each Accident 5,000,000
E.L. Disease -EA Emp 5,000,000
E.L. Disease -Policy 5,000,000
DESCRIPTION OF OPERATIONS / LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached If more space is required)
Workers Compensation:
Policy #: 1705104 (AZ,GA) & WC 001705100 (NJ,PA)
Policy Term: 12/31/14 to 12/31/15
Carrier Name: NEW HAMPSHIRE INS CO (NAIC #:23841)
Limits: E.L. Each Accident / E.L. Disease -Ea Employee / E.L. Disease -Policy Limit - $5,000,000
City of Fort Collins is included as Additional Insured as required by written contract subject to policy terms,
conditions and exclusions with Greyhound Lines, Inc. for leased location at: 250 Mason Street, Ft. Collins, CO.
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
City Of Fort Collins
ACCORDANCE WITH THE POLICY PROVISIONS.
P O Box 580, 117 North Mason Street
Fort Collins CO 80522 USA
AUTHORIZED REPRESENTATIVE
@ 1988-2014 ACORD CORPORATION. All rights reserved.
ACORD 25 (2014101) The ACORD name and logo are registered marks of ACORD
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