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HomeMy WebLinkAboutFMLASOURCE INC - INSURANCE CERTIFICATE (2)ACOR" CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DD/YYYY) 12/24/2018 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: Van Wagner Agency PHONE FAX PO Box 9017 • 800-735-1588 Arc No : 888-290-0302 135 Crossways Park Drive ADDRESS: request@sterlingdsk.com Woodbury NY 11797 INSURER(S) AFFORDING COVERAGE NAIC N INSURED FMLASource, Inc. 455 N.Cityfront Plaza Dr,13thF Chicago IL 60611-5503 A: Granite State Insurance C e: Lexinaton Insurance Com CC)VFRAr:FSt r'FRTIFICOTF NIIMRFR• Q11nR19AA REVISION NHMRFR- 23809 19437 10677 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 SU D POLICY NUMBER YY MWD POLICY EFF D/YY POLICY EXP MM/DDMfW LIMITS C X COMMERCIAL GENERAL LIABILITY Y ETD0517552 1/1/2019 1/1/2020 EACH OCCURRENCE $ 1,000,000 _ CLAIMS -MADE r OCCUR DAMAGE TO RENTPREM IS Ea occuErrence $1,000,000 MED EXP (Any oneperson) $ 5,000 PERSONAL & ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 3,000,000 PRO - POLICY JECTPRO LOC PRODUCTS - COMP/OP AGG $1.000,000 $ OTHER: C AUTOMOBILE LIABILITY ETDO517552 1/1/2019 1/1/2020 COMBINED SINGLE LIMIT Ea accident $ 1,000,000 BODILY INJURY (Per person) $ ANY AUTO BODILY INJURY (Per accident) $ ALL OWNED SCHEDULED AUTOS AUTOS PROPERTY DAMAGE Per accident $ NON -OWNED X HIRED AUTOS X AUTOS A X UMBRELLA LIAB X OCCUR 29-UD-004067327-18 1/1/2018 1/1/2019 EACH OCCURRENCE $ 15,000,000 AGGREGATE $15,000,000 EXCESS LIAB CLAIMS -MADE DED I X I RETENTION $ 1 n rm $ C WORKERS COMPENSATION AND EMPLOYERS' LIABILITY YIN ANY PROPRIETOR/PARTNER/EXECUTIVE EWC 0517556 1/1/2019 1/1/2020 X PER OTH- STATUTE ER E.L. EACH ACCIDENT $1,000,000 OFFICER/MEMBER EXCLUDED? ❑ NIA (Mandatory in NH) E.L. DISEASE - EA EMPLOYEE $1,000,000 E.L. DISEASE - POLICY LIMIT 1 $ 1,000,000 If yes, describe under DESCRIPTION OF OPERATIONS below B Professional 05.317-33-10 1/1/2019 1/1/2020 Per Occurrence 1,000,000 B Liability Privacy & Network Sec Ins TBA 1/1/2019 1/1/2020 Limit $3,000,000 Retro date 1/1/14 DESCRIPTION OF OPERATIONS / LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required( The City of Fort Collins, its officers, agents and employees are included as additional insureds as respect to General Liability as per endorsement form CG2026 and as respect to Auto Liability as per endorsement form 90812 (1-14) to the extent provided therein. CERTIFICATE HOLDER L:ANL:tLLA I IUN :sU uays City of Fort Collins 215 N. Mason Street 2nd Floor 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 ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25 (2014/01) The ACORD name and logo are registered marks of ACORD