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HomeMy WebLinkAbout366358 JVA INC - INSURANCE CERTIFICATE (2)ACCW" ��; CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DD/YYYY) [5/1/2015 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 endorsements . PRODUCER USI Colorado, LLC Prof Liab P.O. Box 7050 Englewood CO 80155 CONTACT NAME PHONE FAX . 800-873-8500 Nq E-MAIL INSURERS AFFORDING COVERAGE NAIC # INSURERA:Charter Oak Fire Insurance Company 25615 INSURED JVAINC INSURERB:Travelers Indemnity Company 25658 JVA, Inc. 1319 Spruce Street Boulder CO 80302 INSURER C: Pinnacol Assurance Company 41190 INSURERD:XL Specialty Insurance Company 37885 INSURER E : Travelers Property Cas. Co. of Amer 25674 INSURER F COVERAGES CERTIFICATE NUMRFR- 106270720 RFVIRIONI NIIMRFR- 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. ILTR TYPE OF INSURANCE INSD WVD POLICY NUMBER MM DDY EFF LIMITS A X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE X� OCCUR Y Y 6801421LB60 /1/2015 EACH OCCURRENCE $1,000,000 DAMAGE TO RENTED PREMISES Ea occurrence $1,000,000 MED EXP (Any one person) $10,000 7- PERSONAL 8 ADV INJURY $1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: POLICYEX] jE O LOC GENERAL AGGREGATE $2,000,000 PRODUCTS - COMP/OP AGG $2,000,000 $ OTHER: EPOLICY AUTOMOBILE LIABILITY Y Y BA16961_578 11/2015 /1/2016 C57BINED S NG E LIMI I$ Ea accident 1,000,000 X ANY AUTO BODILY INJURY (Per person) $ AUTOWNED SCHEDULED BODILY INJURY (Per accident) $ X HIRED AUTOS X NON -OWNED AUTOS PROPERTY DAMAGE Per accident $ $ B X UMBRELLA LIAB X OCCUR Y Y CUP6968Y20A /1/2015 /1/2016 EACH OCCURRENCE $1,000,000 AGGREGATE $1,000,000 EXCESS LIAB CLAIMS -MADE DED X I RETENTIONS 10,000 F $ C WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y / N ANY PROPRIETOR/PARTNER/EXECUTIVE OF CER/MEMBER EXCLUDED? ❑ N /A Y 4131403 /1/2015 /1/2016 �( PER OTH- STATUTE I I ER E.L. EACH ACCIDENT $1,000,000 E.L. DISEASE - EA EMPLOYEE $1,000,000 — - -- $1,000,000 (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below ----- E.L. DISEASE - POLICY LIMIT D Professional Liability Claims Made DPR9723645 /1/2015 5/1/2016 Per Claim 2,000,000 Aggregate 3,000,000 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) As required by written contract or written agreement, the following provisions apply subject to the policy terms, conditions, limitations and exclusions: The Certificate Holder and owner are included as Automatic Additional Insured's for ongoing and completed operations under General Liability; Designated Insured under Automobile Liability; and Additional Insured's under Umbrella / Excess Liability but only with respect to liability arising out of the Named Insured work performed on behalf of the certificate holder and owner. The General Liability, Automobile Liability, Umbrella/Excess insurance applies on a primary and non-contributory basis. A Blanket Waiver of Subrogation applies for General Liability, Automobile Liability, Umbrella/Excess Liability and Workers Compensation. The Umbrella / Excess Liability policy See Attached... I..CR I IrIUM I C nULUCR I.ANk r_LLA I IUN City of Fort Collins Operation Services 300 LaPorte Ave., Building B Fort Collins CO 80521-0000 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 AGENCY CUSTOMER ID: JVAINC AGENCY USI Colorado, LLC Prof Liab POLICY NUMBER CARRIER AUUI I IUNAL KC LOC #: ADDITIONAL REMARKS SCHEDULE NAIC CODE NAMED INSURED JVA, Inc. 1319 Spruce Street Boulder CO 80302 EFFECTIVE DATE: THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, FORM NUMBER: 25 FORM TITLE: CERTIFICATE OF LIABILITY INSURANCE Iprovides excess coverage over the General Liability, Automobile Liability and Employers Liability. City of Fort Collins Page 1 of 1 AL,UKU lUl (LUUt51UI) © 2008 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD