HomeMy WebLinkAboutAP MOUNTAIN STATES DBA ADOLFSON & PETERSON CONSTRU - INSURANCE CERTIFICATE (2),a`oFto® CERTIFICATE OF LIABILITY INSURANCE page 1 of 1
02/(2 /2015
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
CONTACT
NAME
Willis of Minnesota, Inc.
C/o 26 Century Blvd.
P. O. Box 305191
Nashville, TN 37230-5191
PHONE FAX
T: 877-945-7378 UVC N : 888-467-2378
q-MpL certificatea®willis.com
INSURER(S)AFFORDING COVERAGE
NAIC 1!
INSURERA:Arch Insurance Company
11150-900
INSURED
AP Mountain States, LLC
INSURERS: Starr Iadamnity and Liability Company
38318-001
INSURER C: Arch Insurance Company
11150-000
797 Ventura Street
Aurora, CO 80011
INSURER D: Arch Specialty Insurance Company
21199-000
INSURER E:
INSURER F:
COVERAGES CERTIFICATE NUMBER: 22809538 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
TYPEOFINSURANCE
DOL
SUB WyDPOLICY
NUMBER
POLICY EFF
POLICY EXPLTR
LIMITS
A
X
COMMERCIAL GENERAL LIABILITY
y
51PKG8919401
3/1/2015
3/1/2016
EACHOOEC7COUARRENCE
$ 2,000,000
CLAIMS -MADE OCCUR
PREMISES (taEoccccureence)
$ 500,000
X
MED EXP (Any one person)
$ 10,000
Contractual Liability
PERSONAL B ADV INJURY
$ 2,000,000
GEN'L
AGGREGATE LIMIT APPLIES PER:
GENERAL AGGREGATE
$ 4,000,000
POLICY O JECaT LOC
PRODUCTS-COMP/OP AGG
$ 4 000 000
$
OTHER:
A
AUTOMOBILE
LIABILITY
y
51PKG8919401
3/1/2015
3/1/2016
COMBINED )SINGLE LIMIT
$ 1,000,000
X
BODILY INJURY(Per person)
$
ANY AUTO
ALLOWNED SCHEDULED
AUTOS AUTOS
BODILY INJURY(Per accident)
$
HIRED AUTOS AUTOS
Per accident A
$
$
B
UMBRELLAIJAB
X
OCCUR
1000021565
3/l/2015
3/1/2016
EACH OCCURRENCE
$ 1,000,000
X
AGGREGATE
$ 1,000,000
EXCESS LIAR
CLAIM MADE
DED I RETENTION $
$
C
WORKERS COMPENSATION
AND EMPLOYERS' LIABILITY Y
ANY PROPRIETOR/PARTNERIEXECUTIVE O
OFFICER/MEMBER EXCLUDED?
(Mandatory in NH)
ft yes, describe under
DESCRIPTION OF OPERATIONS below
N/A
ADS 51WC18919301
3/l/2015
3/1/2016
PER TH-
X
E.L. EACH ACCIDENT
$ 1,000,000
E.L. DISEASE -EA EMPLOYEE
$ 1,000,000
E.L. DISEASE -POLICY LIMIT
$ 1,000,000
D
'Contractor's
CPP0056620-01
3/1/2015
3 1 2016
Professional(Claims Made)
$1,000,000 Combined Limit
/Pollution Liability
(Occurrence)
$ 250, 000 Deductible - Each Claim
DESCRIPTION OF OPERATIONS/ LOCATIONS/ VEHICLES (ACORD 101, Additonal Remarks Schedule, may be attached if more space is required)
Re: Block 32 Job Number 6753
City of Fort Collins is Additional Insured as respects General and Auto when required by written
contract, agreement or permit executed prior to loss.
City of Fort Collins
Attn: Jill Wilson
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.
AUTHORIZED REPRESENTATIVE
ACORD 25 (2014/01)
Coll:4633631 TT)1:1923815 Cert:
9538
The ACORD name and logo are registered marks of ACORD
TION. All riahts reserved