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608057 GOLD STAR CONCRETE INC - INSURANCE CERTIFICATE
DATE (MMfDDrYYYY) ACORO® CERTIFICATE OF LIABILITY INSURANCE 12/7/2018 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 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 CONTACT NAME:- Scott Anderson _ Commercial Risk Solutions PHONE _IFAX — 6600 E Hampden Ave Ste 200 E-MAIL 303-996-7801;303-757-7719 Denver CO 80224 ADDRESS: sanderson@crsdenver.com INSURERS)iAFFORDING COVERAGE I NAIC # INSURER A: Employers Mutual Casualty Co. 21415 INSURED CAST-2 INSURER B : Pinnacol Assurance 41190 Gold Star Concrete, Inc. _,-----_-._ --__ _ _ - 119 Muriel Dr. INSURER C : — - Northglenn CO 80233 INSURER0: F: COVERAGES CERTIFICATE NUMBER:1382147604 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' 1% bL-jSl7 POLICY EFF� POLICY EXP LTR 11 TYPE OF INSURANCE IR vivn POLICY NUMBER MMIDO/YYYYI. (MMA)DIYYYYI LIMITS A X COMMERCIAL GENERAL LIABILITY j 5XB6615 5/6/2018 5/6/2019 EACH OCCURRENCE $1,000,000 CLAIMS-MADE X ; OCCUR AMAGETb FIFNTEb PREMISES, Ea occurren __ L a_ cBl MED EXP (Any one person) �— -- $ 500,000 I $10,000 PERSONAL & ADV INJURY $1,000,000 AGGREGATE LIMIT APPLIES PER GENERAL AGGREGATE $ 2,000,000 PRODUCTS - COMP/OP AGG $ 2,000,000 — _GEN'L PRO- sl POLICY X ! JECT >� LOD _ — _ OTHER: A AUTOMOBILE LIABILITY 5XS6615 5/8/2018 5/6/2019 COMBINED SINGLE LIMIT 6�acciden0 � __ $1 000 000 BODILY INJURY (Per person) $ X ANY AUTO OWNED SCHEDULED AUTOS ONLY AUTOS I BODILY INJURY (Per accident) $ PROPERTYDAMAGE� JPor agpidenlL___ —._,_..,.. $ X HIRED X NON -OWNED AUTOS ONLY AUTOS ONLY A X UMBRELLA LIAB X I OCCUR 5XB6615 5/6/2018 5/6/2019 EACH OCCURRENCE $ 4,000,000 AGGREGATE $ 4,000,000 EXCESS LIAB CLAIMS -MADE DED RETENTION $ $ B WORKERS COMPENSATION AND EMPLOYERS' LIABILITY I ANYPROPRIETOR/PARTNERlEXECUTIVE Y / N i 4167477 11/12018 11/1/2019 X P� T OT - E.L. EACH ACCIDENT - $ 500,000 OFFICERiMEMBEREXCLUDED? y (Mandatory In NH) N yes, describe under 'DESCRIPTION OF OPERATIONS below N/A ---"---- E.L. DISEASE - EA EMPLOYEE E.L.DISEASE - POLICY LIMIT -" $ 500,000 $ 500,000 DESCRIPTION OF OPERATIONS ! LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) Certificate holder is included as additional insured on the General Liability with respect to ongoing and completed operations of the named insured for the certificate holder as required by written contract. All policy terms, conditions and exclusions apply. City of Fort Collins Purchasing Department P.O. Box 580 Fort Collins CO 80522 LAI 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 �.lf�,�-� ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD 2 of 3 3336