HomeMy WebLinkAbout608057 GOLD STAR CONCRETE INC - INSURANCE CERTIFICATE (2)AC� a DATE (MM/DD/YYYY)
� CERTIFICATE OF LIABILITY INSURANCE 1217/2018
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 -- Fax -- -
6600 E Hampden Ave Ste 200 - 303-996-7801 A!c No): 303-757-7719
Denver CO 80224 ADDRESS: sanderson crsdenver.com
INSURER A: Employers Mutual Casualty Co. 21415
INSURED GOLST-2 INSURERB:_Pinnacol-Assurance
Gold Star Concrete, Inc. - " — ",---�`
119 Muriel Dr.
INsuRERc`------
Northglenn CO 80233 INSURER_D;—_.___�--
INSURER E
CnVFRAGFS CFRTIFICATF NUMBER-iRsni95n1s 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.
--.—. _ .
T--S B Y EXP
INSR
�IpYEFF
LTR TYPEOFINSURANCE POLICY NUMBER MMP MNbDlYYYY LIMITS
A
X COMMERCIAL GENERAL LIABILITY
5XB6615
5/6/2018
5/6/2019
EACH OCCURRENCE_
$1,000,0DO
AMAGE TO F?EIQ'rED
_
J CLAIMS -MADE OCCUR
$ 500,000
_EREMISES_(Ea_occurrenc-)
I MED EXP (Any oneperso9
$10000---_.-.
PERSONAL 8 ADV INJURY
$1 000 000
GENERAL AGGREGATE
GEN'L AGGREGATE LIMIT APPLIES PER:
i
1 $ 2,000,000
PRODUCTS- COMP/OP AGG
POLICYW` X� JE O- LOC
$ 2,000,000
OTHER:
A
AUTOMOBILE LIABILITY
5XB6615
5/6/2018
5/6/2019 COMBINED SINGLE LIMIT
-(E-@ accident
$1,000,000
X ANY AUTO
I BODILY INJURY (Per person)
$
OWNED SCHEDULED
BODILY INJURY (Per accident)
$
AUTOS ONLY AUTOS
-
$
X HIRED
X
I d AMAGE
AUTOS ONLY AUTOS ONEDY
(Par acE
$
A
X UMBRELLALIAB X .00CUR
5X86615
5/6/2018
5/6/2019 EACH OCCURRENCE
$41000,000
EXCESS LIAB _ CLAIMS MADE
AGGREGATE
$ 4,000,000
DED ! RETENTION $
$
g WORKERS COMPENSATION
4187477
11/1/2018
11/1/2019 X i STATUTE ' 1 OERH
AND EMPLOYERS' LIABILITY YIN
ANYPROPRIETOR/PARTNER, EXECUTIVE
E.L. EACH ACCIDENT
-----
$ 500,DGO
`---
OFFICER/MEMBER EXCLUDED?
NIA
(Mandatory In NH)
E.L. DISEASE - EA EMPLOYEE
$ 500,000
tF yes. describe under
- DESCRIPTION OF OPERATIONS below
—
E.L DISEASE- POLICY LIMIT
- - -
$ 500,000
i
I
DESCRIPTION OF OPERATIONS / LOCATIONS I 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.
rtFRTIFICATF HOI IIFR CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
City of Fort Collins
ACCORDANCE WITH THE POLICY PROVISIONS.
Purchasing Department
AUTHORIZED REPRESENTATIVE
P.O. Box 580
Fort Collins CO 80522
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A
U 1988-2015 ACORD CORPORATION. All rights reserved.
ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD
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