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HomeMy WebLinkAboutFMLASOURCE INC - INSURANCE CERTIFICATE (3)CERTIFICATE OF LIABILITY INSURANCE IYYYY) DATE (MMIDD(MMIDD9 , 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:PHONE Van Wagner Agency PO Box 9017 FAX M. • 800-735-1588 Arc No : 888-290-0302 135 Crossways Park Drive ADDRE : requestasteriing risk. com INSURERS AFFORDING COVERAGE NAIL# Woodbury NY 11797 INSURER A: Lexington Insurance Company 19437 _ INSURED INSURERS: Cincinnati Insurance Company 10677 FMLASource, Inc. 455 N.Cityfront Plaza Dr,13thF INSURERC: Chicago IL 60611-5503 INSURERD: INSURER E : INSURER F : COVERAGES CERTIFICATE NUMBER: 1499419750 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 SUER POLICY NUMBER MM DPOLI CY EFF DIYYYY POLICY EXP D MMD/YYYY LIMITS B X COMMERCIAL GENERAL LIABILITY Y ETD0517552 1/1/2019 1/1/2020 EACH OCCURRENCE $ 1,000,000 T RENTED CLAIMS -MADE X .I OCCUR PREMDAMAGE PREMISES Ea occurrence $1,000,000 MED EXP (Any one person) $ 5,000 PERSONAL & ADV INJURY $ 1,000.000 GEN'L AGGREGATE LIMIT APPLIES PER' GENERAL AGGREGATE $ 3,000,000 POLICY PRO- JECT LOC PRODUCTS -COMP/OP AGG $ 1,000.000 $ OTHER: B AUTOMOBILE LIABILITY ETD0517552 1/l/2019 1/1/2020 COEaMBINED accident SINGLE LIMIT $ 1,000,000 BODILY INJURY (Per person) $ ANY AUTO ALL OWNED SCHEDULED AUTOS AUTOS BODILY INJURY (Per accident) $ PROPERTY DAMAGE Par.cadent $ X HIREDAUTOS X AUTOS NON-OWNED $ 8 X UMBRELLA LIAB I X JOCCUR ETD0517552 1/1/2019 1/1/2020 EACH OCCURRENCE $10,000,000 AGGREGATE $10,000.000 EXCESS LIAB CLAIMS -MADE DIEDX RETENTION $ in rinin $ B WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y / N EWC 0517556 1/1/2019 1/1r2020 X PER STATUTE ERH ANY PROPRIETOR/PARTNER/EXECUTIVE E.L. EACH ACCIDENT $ 1,000,000 OFFICER/MEMBER EXCLUDED? ❑ N /A (Mandatory in NH) E.L. DISEASE - EA EMPLOYEd $ 1,000,000 If yes, describe under DESCRIPTION OF OPERATIONS below I E.L. DISEASE - POLICY LIMIT 1 $1,000,000 A Professional 05-317-33-10 1/1/2019 1/1/2020 Per Occurrence 1,000,000 A Liability TBA 1/1/2019 1/1/2020 Privacy & Network Sec Ins 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. City of Fort Collins 215 N. Mason Street 2nd Floor Fort Collins, CO 80522 Lh110 Lela 0I/a11 I M 0111 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