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HomeMy WebLinkAboutTRI-STATE OIL RECLAIMERS INC - INSURANCE CERTIFICATE (2)TRI-OIL-01 DEBELLAJO ,4coR0 CERTIFICATE OF LIABILITY INSURANCE DAT/YYYY) �-/ 2/13/2D13/2015 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 USI Insurance Services LLC 1904 Warren Avenue Cheyenne, WY 82001 INSURED Tri-State Oil Reclaimers, Inc. 1770 Otto Road Cheyenne, WY 82007 I n/C "N Fife (307) 635-4231 1 iA c. Ner. (307) 635-4237 I INSURER F : INSURER(S) AFFORDING COVERAGE NA Admiral Insurance Company 24856 Great West Casualty Company 11371 RSUI Indemnitv COmDanv 22314 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. IN$R LTR TYPE OF INSURANCE POLICYNUMBER MMDDYIYYYY MML ICY EXP DD/YYYY LIMITS A X COMMERCIALGENERALLIABILITY CLAIMS -MADE a OCCUR FElEIL1952000 05/16/2014 05/16/2015 EACH OCCURRENCE S 1,000,00 PREMISES Eaocwrrence $ 100,00 MED EXP (Any one person) $ 6,00 PERSONAL B ADV INJURY $ 1,000,00 GEML AGGREGATE LIMIT APPLIES PER: POLICY F1 PE0 LOC OTHER: GENERAL AGGREGATE $ 2,000,00 PRODUCTS-COMP/OP AGG $ 2,000,00 $ B AUTOMOBILE LIABILITY ANY AUTO ALL OWNED X SCHEDULED AUTOS AUTOS X HIRED AUTOS X NON -OWNED AUTOS CLP81745R 02/15/2015 02/15/2016 COMBINED SINGLE LIMIT Ea accidentr $ 1,000000 BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ PROPERTY DAMAGE (Para ident $ $ C X UMBRELLA LIAB EXCESS LIAB X OCCUR CLAIMS -MADE NHAO70887 02/16/2015 02/15/2016 EACH OCCURRENCE $ 1,000,00 AGGREGATE $ 1,000,00 DED RETENTION $ $ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y / N ANY PROPRIETOR/PARTNER/EXECUTIVE ❑ OFFICER/MEMBER EXCLUDED? (Mandatory in NH) If yes. describe under DESCRIPTION OF OPERATIONS below N/A PER OTH- STATUTE ER E.L. EACH ACCIDENT S E.L. DISEASE - EA EMPLOYE $ E. L. DISEASE -POLICY LIMIT I $ B A ICargo Liability �Emp Liab/Stop Gap CLP81745R FElEIL1952000 02/15/2015 05/16/2014 02/15/2016 'Per Auto/$2500 Ded 10,000 05/16/2015 See Below DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) Employers Liability/Stop Gap Limit $1,000,000 AccidenUEmployee/Aggregate CERTIFICATE HOLDER CANCELLATION City of Fort Collins Environmental Service Div Attn: Carol Webb PO Box 580 Fort Collins, CO 80522.0580 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 © 1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25 (2014/01) The ACORD name and logo are registered marks of ACORD Page 1 of 2 A`OR" CERTIFICATE OF LIABILITY INSURANCE DA05/14TE /2 Y4 OS/14 /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 endorsement(s). PRODUCER Willis of Wyoming, Inc. c/o 26 Century Blvd CONTACT NAME: PHOAX NE .1-877-945-7378 A/C No:1-888-467-2378 P.O. Box 305191 ADDRESS: certificates@willis. com Nashville, IN 372305191 USA INSURERS AFFORDING COVERAGE NAIC i INSURER A: Admiral Insurance Company 24856 INSUREgl,ri-State Oil Reclaimers, Inc. INSURER B:Great West Casualty 11371 INSURER C:RSOI Indemnity Company 22314 1770 Otto Road Cheyenne, WY 82007 INSURERD: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: W361429 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 ADDL INSIR SUER WUM POLICY NUMBER POLICY EFF MM/DDIYYYYJ POLICY EXP (MMIDDNYYYI UWTS GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 A X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE O OCCUR PR I Ea occurre nce $ 300,000 MED EXP(Any one person) $ 5,000 PERSONAL B ADV INJURY $ 1,000,000 EIL10101255701 05/16/2014 05/16/2015 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS -COMPIOP AGG $ 2,000,000 POLICY 71 PRO-JFCT LOC $ AUTOMOBILE UABILRI' COMBINED SINGLE LIMIT Eaaccident) 1,000,000 BODILY INJURY (Par person) $ ANY AUTO H ALL OWNED X SCHEDULED AUTOS AUTOS CLP81745Q 02/15/2014 02/15/2015 INJURY BODILY INRY(Par accident ) $ X HIRED AUTOS NON -OWNED AUTOS PROPERTY DAMAGE Per a nt $ $ C X UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 1,000,000 AGGREGATE $ 1,000,000 EXCESS LIAB CLAIMS -MADE NRA066652 02/15/2014 02/15/2015 DELI RETENTION $ $ WORKERS COMPENSATION WC STATU- OTH- AND EMPLOYERS' LIABILITY YIN ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? ❑ NIA C E.L. EACH ACCIDENT $ E.L DISEASE - $ (Mandatory In NH) H yes, descnbe under DESCRIPTION OF OPERATIONS below "EMPLOYE E.L. DISEASE - POLICY LIMIT $ B Cargo Liability CLP81745Q 02/15/2014 02/15/2015 er Auto: $20,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101, Additional Remarks Schedule, d more spa" Is required) City of Fort Collins Environmental Service Div Attn: Carol Webb PO Box 580 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 ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25 (2010/05) The ACORD name and logo are registered marks of ACORD SR ID: 4779244 SATCH:Hatoh R: 54716 AGENCY CUSTOMER ID: LOC #: A oizo® ADDITIONAL REMARKS SCHEDULE Page 2 Of 2 AGENCY NAMED INSURED Willis of Wyoming, Inc. Tri-State Oil Reclaimers, Inc. 1770 Otto Road POLICY NUMBER See Page 1 Cheyenne, WY 82007 CARRIER NAIC CODE See Page 1 See Page 1 EFFECTIVE DATE: See Page 1 RCMMMINO THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, FORM NUMBER: 25 FORM TITLE: Certificate of Liability Insurance INSURER AFFORDING COVERAGE: Admiral Insurance Company POLICY NUMBER: EIL10101255701 EFF DATE: 05/16/2014 EXP DATE: 05/16/2015 TYPE OF INSURANCE: Employers Liability /Stop Gap ACORD 101 (20081011 LIMITS: $1,000,000 Each Accident $1,000,000 Each Employee $1,000,000 Aggregate NAIC#: 24856 CCi 2(IOA ArOPII CCIRPOPATION All rinhfc rnenrvurl The ACORD name and logo are registered marks of ACORD 4779244 Batch #: 54716 W361429