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Home My WebLink AboutCORRESPONDENCE - PURCHASE ORDER - 9185788ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? INSR ADDL SUBR LTR INSD WVD PRODUCER CONTACT NAME: PHONE FAX (A/C, No, Ext): (A/C, No): E-MAIL ADDRESS: INSURER A : INSURED INSURER B : INSURER C : INSURER D : INSURER E : INSURER F : POLICY NUMBER POLICY EFF POLICY EXP TYPE OF INSURANCE (MM/DD/YYYY) (MM/DD/YYYY) LIMITS AUTOMOBILE LIABILITY UMBRELLA LIAB EXCESS LIAB WORKERS COMPENSATION AND EMPLOYERS' LIABILITY DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) AUTHORIZED REPRESENTATIVE EACH OCCURRENCE $ CLAIMS-MADE OCCUR DAMAGE TO RENTED PREMISES (Ea occurrence) $ MED EXP (Any one person) $ PERSONAL & ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ POLICY PRO- LOC JECT PRODUCTS - COMP/OP AGG OTHER: $ COMBINED SINGLE LIMIT (Ea accident) $ ANY AUTO BODILY INJURY (Per person) $ OWNED SCHEDULED AUTOS ONLY AUTOS BODILY INJURY (Per accident) $ HIRED NON-OWNED PROPERTY DAMAGE AUTOS ONLY AUTOS ONLY (Per accident) $ $ OCCUR EACH OCCURRENCE CLAIMS-MADE AGGREGATE $ DED RETENTION $ PER OTH- STATUTE ER E.L. EACH ACCIDENT E.L. DISEASE - EA EMPLOYEE $ If yes, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT INSURER(S) AFFORDING COVERAGE NAIC # COMMERCIAL GENERAL LIABILITY Y / N N / A (Mandatory in NH) SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD ! ,- (/ (< 0 E= (0- -(-> . 1 - / ((( (.. / 1 : ((- (- (- ( ( ( ( 1 1. / 1/ ( / / / ((- / > ( ! D(- / (((- ..((- ..( . (-01 ...( 4+*,$ *(*+. ,./0,49 1/ ..((- ..( . ; . ( ( 1 ((- (00/ - (- ..( . (- ( ! ! 3; . (- ( ( 1 (B ! 4 . (- // 5( -0(-) ( B 0- - ,- . ( - ( (- // 5( -0(-) ( DocuSign Envelope ID: A86493EA-2F36-4AE3-9AB1-76327EC7E515 !"#$%& ' () (!*+*+ ! "# ! #$ %& $ # ' ,- . (. / .. . (-01! "22'3"456''3455475,8"9'346'43, # ())*+*,-,./0) 0.,1.2 00,*3+*,1.2 4+*,1.250)60+*,. 4/ 1 : ((- ( 0 1 / / ( / / / (0- - / % 111/ ( ( ( 0- % - / 111/ ( ( % 1 ..( . ; . 0 (( ( ( 0 (( 1 ((- ( < . ( (= ./ ..(-< .> = </ / (. 1= ( (-</ . . ( 1> = ( ((. ; (((-? ((- ( ( 1 ( 4 ( (0- -(- . . / 1 11/ ( ( ; .( /((- -. ( -0 0 -0(-) ( ! 4+*,$ %7.,,./0) ..( . ..( .(-/ @ A 1 : (@ A -0 (- -. ( 0(- / (( ( < . > =</ / (. 1= </ . . ( 1 > = .0- / ( ! ! 8 ( B ! ,- ( (- (1 - B (-/ 11/ ( (- ..( .@ A ((- (@ A. 1 (. C0 ! ! ,- ..( - ..( . // ( (-?((/ ((. 0B . ! 1/ ..((- ..( . ; . ( ( 1 ((- ..( - ..( . 0( . (- (- (0- - ; . (- ( ( 1 ((/ . - ..( . 8! D(- / (((- ..((- ..( . (-01 ..( ? //! ,- . ( //(< .> = </ / (. 1= 1 ( ! ! 40 E .1 ( / ( ; /( -. (0(- - 0 E(-/ > (@(- (- ( / A( / . - (- ..( .@ A ((- ( (- ./ ( - /(.B DocuSign Envelope ID: A86493EA-2F36-4AE3-9AB1-76327EC7E515 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. 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 endorsement(s). COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: CERTIFICATE HOLDER CANCELLATION ACORD 25 (2016/03) © 1988-2015 ACORD CORPORATION. All rights reserved. CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DD/YYYY) $ $ $ $ $ The ACORD name and logo are registered marks of ACORD IKOVACEVIC 12/10/2018 DECCINT-01 B BA5227L950 C UB2L206580 A CO00000013916 A CO00000013916 1,000,000 1,000,000 1,000,000 2,000,000 1,000,000 5,000,000 5,000 50,000 3,000,000 1,000,000 X X X X X X A CO00000013916 License # 0C36861 07/14/2018 07/14/2019 01/08/2018 01/08/2019 07/14/2018 07/14/2019 01/08/2018 01/08/2019 01/08/2018 01/08/2019 The City of Fort Collins, its officers, agents, and emplyees are named as additional insureds as respects to general liability and automobile liability for the ongoing operations of the Named Insured. Inland Empire-Alliant Insurance Services, Inc. 735 Carnegie Dr Ste 200 San Bernardino, CA 92408 (909) 886-9861 (909) 886-2013 Poudre Fire Authority 102 Remington St Fort Collins, CO 80524 Deccan International 5935 Cornerstone Crt W Ste 230 San Diego, CA 92121 Admiral Indemnity Company Travelers Indemnity Company of Connecticut Travelers Property Casualty Company of America 44318 25682 25674 X X Aggregate Cyber Liability 10,000,000 1,000,000 Professional Liab. Cyber Liability DocuSign Envelope ID: A86493EA-2F36-4AE3-9AB1-76327EC7E515