HomeMy WebLinkAbout129556 DELTA DENTAL OF COLORADO - INSURANCE CERTIFICATEP$26(M)28(N'2
DATE (M
M1DDfYYYY%�� 12/04/2018ilew� r
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AC40R
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 endorsement(s).
PRODUCER 1-303-534-4567 1 CONTACT
NAME:
IMA, Inc. - Colorado Division PHONE FAX
... _ �_..,_ IANn\
1705 17th Street
Suite 100
Denver, CO 80202
INSURED
Delta Dental of Colorado
Colorado Dental Service Inc. dba
4582 S. Ulster St., Suite 800
.com
INSURERA: FEDHRAL INS CO (Chubb)
INSURERS:TRUMBULL INS CO(Hartford Ins
20281
27120
IDenyei CO 80237 1INSURER F• I I
/�f-l9TIC1/�ATG unuoco. Fd(or.121 RFVISIAN NIIII
vTHIS 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.
NSR ADDL SUER POLICY EFF POLICY EXP
ILTR TYPE OF INSURANCE INS13 Wvo POLICY NUMBER MMIDD MMIDD LIMITS
A
X
COMMERCIAL GENERAL LIABILITY
35775020
11/12/18
11/12/19
EACH OCCURRENCE
$ 1,000,000
CLAIMS -MADE 1XI OCCUR
PREMISES Ea occurrence)
$ 1,000,000
MED EXP (Any one person)
$ 10,000
PERSONAL & ADV INJURY
$ 1,000,000
GEN'L AGGREGATE LIMIT APPLIES PER:
GENERAL AGGREGATE
$ 2,000,000
PRODUCTS. COMP/OPAGG
$ Included
POLICY D PRO LOC
JECT
E
OTHER:
A
AUTOMOBILE LIABILITY
1870207861
11/12/18
11/12/19
COEaMBINccidentarl N LELIMIT
a
$ 1,000,000
BODILY INJURY (Per person)
$
ANY AUTO
BODILY INJURY (Per accident)
$
OWNED SCHEDULED
AUTOS ONLY AUTOS
HIRED NON -OWNED
X AUTOS ONLY X AUTOS ONLY
PROPERTY DAMAGE
Per accident
$
$
A
X
UMBRELLA LIAB
X
OCCUR
79790815
11/12/18
11/12/19
EACH OCCURRENCE
$ 1,000,000
AGGREGATE
$ 1,000,000
EXCESS LIAR
CLAIMS -MADE
DIED X RETENTION $ 0
$
B
WORKERS COMPENSATION
AND EMPLOYERS' LIABILITY Y / N
ANYPROPRIETORIPARTNER/EXECUTIVE
OFFICER/MEMBEREXCLUE
(Mandatory in NH)
N/A
3491ISCI80656
08/01/18
OB/Ol/19
X STATUTE ERH
E.L. EACH ACCIDENT
$ 500,000
E.L. DISEASE- EA EMPLOYEE
$ 500, 000
E.L. DISEASE -POLICY LIMIT
$ 500,000
If yes, describe under
DESCRIPTION OF OPERATIONS below
1 Additional Remarks Schedule may DESCRIPTION OF OPERATIONS 1 LOCATIONS I VEHICLES (ACORD 101, d Y be attached If more space is required)
City of Fort Collins is included as Additional Insured on the General and Automobile Liability Policies if required by
written contract or agreement subject to the policy terms and conditions.
I SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
City of Fort Collins THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
PO Box 580 AUTHORIZED REPRESENTATIVE fir/ /��//;�
Fort Collins, CO 80522 / /
I USA CCC
V 1yS8-LU10 AI.UKU 6UKrvK14I IUrl. Mil nyncs Iroservcu.
ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD
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