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Home My WebLink AboutEVANS TRUCKING LLC - INSURANCE CERTIFICATE (5)05-31-3535839-2 Shelter Mutual Insurance Company 1817 W Broadway Columbia, MO 65218 1-800-SHELTER (743-5837) General Liability Insurance Policy Declarations ***MANUAL DEC*** Named Insured: EVANS TRUCKING LLC Policy Number: 05-31-3535839-2 6490 N COUNTY ROAD 3 Effective Date: 04/16/2015 (01:56 P.M. CST) FORT COLLINS CO 80524-9304 Expiration Date: 08/29/2015 (12:01 A.M. CST) Notice to the Mortgagee/Loss Payee/Addl Insured: Your interest will be continuous until cancellation notice is mailed to you. These Declarations are part of your policy and replace all prior Declarations. Business of the Named Insured: HAULS DIRT/ROCK Agent: BRUCE JOHNSON AGENCY INC 05-05549-10 PO BOX 270663 FORT COLLINS CO 80527 970-226-5034 The Named Insured is a(n): Corporation Audit Period: Annually ^IIItItS 6i General Aggregate (Other Than Products — Completed Operations) $2,000,000 Products — Completed Operations Aggregate Limit (See Each Classification Below) Included Personal And Advertising Injury Limit $1,000,000 Each Occurrence Limit $1,000,000 Rented To You Limit $100,000 Any One Premises Medical Expense Limit $5,000 Any One Person Premium Bases Rates Advance (Annual) Premium PREMISES & OPERATIONS- 99793 TRUCKERS PAYROLL PER $1000 5.799 $168.00 INCLUDING PRODUCTS &/OR COMPLETED OPERATIONS $28,980 ITEM ZIP CODE: 80524 PREMISES & OPERATIONS- 88801 PREMIUM CHARGE FOR REINSURANCE OF $500,000 $938.00 OCCURRENCE, EXCESS OF $500,000 OCCURRENCE. ITEM ZIP CODE: 80524 6490 N COUNTY ROAD 3 FORT COLLINS CO Limits Deductible _ Number Premium Additional Insured - Owners, Lessees or Contractors - CG 20 10 04 13 S 17.00 Scheduled Person or Organization MARTIN MARIETTA MATERIALS Additional Insured - Owners, Lessees or Contractors - CG 20 10 04 13 $17.00 Scheduled Person or Organization BIVENS TRUCKING AND EXCAVATING Additional Insured - Owners, Lessees or Contractors - CG 20 10 04 13 $17.00 Scheduled Person or Organization CONNELL RESOURCES INC Additional Insured - Owners, Lessees or Contractors - CG 20 10 04 13 $17.00 Scheduled Person or Organization CITY OF FORT COLLINS Additional Insured - Owners, Lessees or Contractors - CG 20 10 04 U $17.00 kf Page 1 05-31-3535839-2 Scheduled Person or Organization COULSON EXCAVATING Total for Term (This is Not a Bill): $1,191.00 Policy forms and ad4oional endorsements attached to this policy Number Commercial General Liability Coverage Form CG 00 0104 13 Exclusion - Damage To Work Performed By Subcontr On Your Behalf CG 22 94 10 01 Fungi Or Bacteria Exclusion CG 2167 12 04 Total Pollution Exclusion Endorsement CG 2149 09 99 Exclusion - Exterior Insulation And Finish Systems CG 21 86 12 04 Mutual Policy Notification S-18-S Colorado Changes - Civil Union IL 0125 11 13 Amendatory Endorsement G-252.1-G Non -Binding Arbitration CG 24 01 12 04 Employment -Related Practices Exclusion CG 2147 12 07 Exclusion - Access Or Disclosure Of Information CG 2107 05 14 Lead Poisoning Exclusion Endorsement B-601-B Asbestos Exclusion B-559-B Nuclear Energy Liability Exclusion Endorsement (Broad Form) IL 00 2109 08 Common Policy Conditions IL 00 17 1198 Colorado Changes - Cancellation And Nonrenewal IL 02 28 09 07 Limitation Of Coverage To Designated Premises Or Projects End #1 CG 2144 07 98 Addl Insured MARTIN MARIETTA MATERIALS 2710 WYCLIFF RD RALEIGH NC 27607-3033 A CITY OF FORT COLLINS PO BOX 580 FORT COLLINS CO 80522-0580 COULSON EXCAVATING 3609 N COUNTY ROAD 13 LOVELAND CO 80538-2316 Addl Insured BIVENS TRUCKING AND EXCAVATING 862 W WILLOX LN FORT COLLINS CO 80524-1147 Addl Insured Omsk- CONNELL RESOURCES INC 5150 SE FRONTAGE RD FORT COLLINS CO 80528-9526 kf Page 2 05-31-3535839-2 (For Office Use Only) Transaction: P.C. H. O. CODE: 1,191.00 Policy ID: 66004218766 Date Issued: 04-17-2015 Policy Term: One Year 'l 1252014' G-2.10-G kf Page 3