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HomeMy WebLinkAboutJIM BLACK CONSTRUCTION INC - INSURANCE CERTIFICATEACORO0 `� CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DD/YYYY) 9/28/2018 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: PNONE (661)266-9390 A/C No: (661)266-9391 ADMRIess:Certs@DriscollandDriscoll.com Driscoll & Driscoll Insurance Agency, Inc. 41235 llth St West, Suite A INSURERS AFFORDING COVERAGE NAIC# INSURERA:Tokio Marine Specialty Insurance Co Palmdale CA 93551 INSURED INSURER B:Philade l hia Indemnity Insurance Co INSURER C : INSURERD: Jim Black Construction, Inc. I INSURER E: 12279 Pennsylvania Street 1INSURERF: Thornton CO 80241 COVERAGES CERTIFICATE NUMBER:CL1892806094 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 UBR POLICY NUMBER POLICY EFF MM/DD/YYYY POLICY EXP MM/DD/YYYY LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 11000,000 A CLAIMS -MADE ❑X OCCUR 1AGE TO TED PREMISES(E. otccurrence)$ 100,000 MED EXP (Any one person) $ 5,000 PPK1887098 10/1/2018 10/1/2019 PERSONAL & ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 POLICY PRO- JECT LOC PRODUCTS - COMP/OPAGG $ 2,000,000 $ OTHER: AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea accident $ 1,000,000 BODILY INJURY (Per person) $ B ANY AUTO ALL OWNED SCHEDULED AUTOS AUTOS PHPKI887042 10/1/2018 10/1/2019 X BODILY INJURY (Per accident) $ X PROPERTY DAMAGE Per accident $ NON -OWNED HIRED AUTOS LAUTOS UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 4,000,000 X AGGREGATE $ 4,000,000 A EXCESS LIAB CLAIMS -MADE DED RETENTION $ PUB649022 10/1/2018 10/1/2019 WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y / N PER OTH- STATUTE I I ER ANY PROPRIETORIPARTNER/EXECUTIVE E.L. EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? ❑ N / A E.L. DISEASE - EA EMPLOYE $ (Mandatory In NH) If yes, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT $ A Contr Po l lution Liability PPK1887104 10/1/2018 10/1/2019 Per Occ/Agg 1 M / 2 M A Professional Liability PPK1887104 10/1/2018 10/1/2019 Claims Made 1,000,000 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached If more space is required) ** For Informational Purposes Only ** CERTIFICATE HOLDER CANCELLATION City of Fort Collins P.O. 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 Ross Driscoll, Sr/DM��� ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25 (2014/01) INS025 (201401) The ACORD name and logo are registered marks of ACORD