HomeMy WebLinkAboutWING SHACK ENTERPRISES INC - INSURANCE CERTIFICATE (2)�•� WINGS-6
OP ID: B3
DATE(M1110212018
/2018
'4� RAP CERTIFICATE OF LIABILITY INSURANCE
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 have ADDITIONAL INSURED provisions or 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 970-482-7747
Brown & Brown Inc
4532 Boardwalk Dr, Suite 200
Fort Collins, CO 80525
C NTACT Karen E. Siwek, CPA _
PHONE 970-482-7747 FAX 970-484-4165
(A/C, No, Ext): I (A/C, N_o):
E-M IL kS!wek@bbcolorado.com
Karen E. Siwek, CPA
INSURERS AFFORDING COVERAGE
NAIC #
INSURER A: Westfield Insurance Company
24112
_
INSURED Win gg Shack Enterprises, Inc.
Edith Georgge
2990 West 29th Street, Unit A2
INSURERB:
-
INSURER C
INSURER D :
Greeley, CO 80631
INSURER E:
INSURER F
rCoTtrirATc Wrl\AQCG• REVISION NUMBER:
tluvammu CJ a 1 r,r rv�," REVISION _ .__---_— -
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.
INSL LT,R TYPE OF INSURANCE DDL UBR POLICY NUMBER POLICY EFF POLICY EXP LIMITS
TR MMIDDIYY
A
X
COMMERCIAL GENERAL LIABILITY
EACH OCCURRENCE
$ 1,000,000
A
CLAIMS -MADE OCCUR
',CWP5054822
CWP8602741
11/15/2018
11/15/2018
11/15/2019
11/15/2019
pREMGETOR "Curren
SQQ,QQQ
MEDEXP (Any oneperson)
5,000
PERSONAL & ADV INJURY
1,000,000
GEN'L AGGREGATE LIMIT APPLIES PER:
POLICY ❑ PROT LOC
JEC
GENERAL AGGREGATE
2,000,
PRODUCTS - COMP/OP AGG
00
$ 2,000,000
OTHER
A
AUTOMOBILE LIABILITY
COMBINED SINGLE LIMIT
Ea a i n
1,000 000
$ _
BODILY INJURY Perperson)
X ANY AUTO
CWP5054822
11/15/2018
11/15/2019
$ _
BODILY INJURY Per accident
$
OWNED SCHEDULED
AUTOS ONLY AUTOS
HIRED NON -OWNED
AUTOS ONLY AUTOS ONLY
PerOPERaccint AMAGE
- -
A
UMBRELLA LIAB
EXCESS LIAB
OCCUR
CLAIMS -MADE
CWP5054822
11/15/2018
11/15/2019
EACH OCCURRENCE
$ 2'QQ O'000
$ 2,000,000
AGGREGATE
DED I X I RETENTION $ 0
A
WORKERS COMPENSATION
AND EMPLOYERS' LIABILITY YIN
ANY PROPRIETOR/PARTNER/EXECUTIVE
FManUER/M la BER EXCLUDED? 1
NH)E.L.
If yes, describe under
DESCRIPTION OF OPERATIONS below
N / A
WCP5055634
11J15/2018
11/15/2019
PER OTH-
T TE
E.L. EACH ACCIDENT
1,000,000
DISEASE - EA EMPLOYE
1,000,000
E.L. DISEASE -POLICY LIMIT
1,000,000
DESCRIPTION OF OPERATIONS / LOCATIONS 1 VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required)
City of Fort Collins is included as additional insured per policy forms and
conditions on page 2.
CITYF10
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
City of Fort Collins
215 N. Mason St.
Fort Collins, CO 80521 AUTHORIZED REPRESENTATIVE
Karen E. Siwek, CPA
ACORD 25 (2016/03) v laaa-cv la t.vrcu wrcrvR.,r �.,...,triyiraa
The ACORD name and logo are registered marks of ACORD