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HomeMy WebLinkAbout113275 ALM2S - INSURANCE CERTIFICATE (2)ALM2S-1 CERTIFICATE OF LIABILITY INSURANCE DATE(M6120 03/2l209 19 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 'Ur V-004-r IYr NvME�V r%alcn I-. J1WCn, a.rn Brown & Brown Inc PHONE 970-482-7747 FAX 970-484-4165 4532 Boardwalk Dr, Suite 200 (A/C, No, Ext): A/C, No): Fort Collins, CO 80525 AODRE slave CO Ora O.com Karen E. Siwek, CPA INSURER S AFFORDING COVERAGE NAIC # INSURER A: Pinnacol Assurance Company 41190 INSURED alm2s INSURER B: Westfield Insurance Company 124112 712 Whalers Way, Ste. B-100 Admiral IC24856 Fort Collins, CO 80525 INSURER C :mransurance Company y rnVFRAnPq rGRTIPICATIP KII IIURGR• 9)FVICI(11d KII IMRGR• 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 LTIR TYPE OF INSURANCE DDL SUER POLICY NUMBER POLICY EFF POLICY EXP LIMITS B X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE I OCCUR Y BOP3719966 04/01/2019 04/01/2020 EACH OCCURRENCE $ 1,000,000 DAMAGETO100,000 PREMISES MED EXP (Any oneperson) 5,000 X EBL/EPL PERSONAL & ADV INJURY 1,000,000 GEN'L X AGGREGATE LIMIT APPLIES PER: POLICY JECT LOC OTHER: GENERAL AGGREGATE 2,000,000 PRODUCTS - COMP/OP AGG 2,000,000 Emp Ben. 1,000,000 B AUTOMOBILE LIABILITY ANY AUTO OWNED SCHEDULED AUTOS ONLY AUTOS AUTOS ONLY NON -OWNED BOP3719966 04/01/2019 04/01/2020 COMBINED SINGLE LIMIT (Ea aG nl 1,000,000 $ X BODILY INJURY Perperson) BODILY INJURY Per accident $ PROPERTY AMAGE Per accident B X UMBRELLA LIAB EXCESS LIAB X OCCUR CLAIMS -MADE BOP3719966 04/01/2019 04/01/2020 EACH OCCURRENCE 2,000,000 AGGREGATE 2,000,000 DED I X I RETENTION $ 0 A WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE YIN OFi-10EiZ'MEMD' LXCLUCED? n (Mandatory In NH) LJ If yes, describe under DESCRIPTION OF OPERATIONS below NIA 1951272 04/01/2019 04/01/2020 X PTR T OTH- E.L. EACH ACCIDENT 1,000,000 E.L. DISEASE - EA EMPLOYEE $ A00,000 E.L. DISEASE - POLICY LIMIT 1,000,000 C Professional E0000037269-03 04/01/2019 04/01/2020 Ea Claim Aggregate 2,000,000 2,000,000 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) The City of Fort Collins is named additional insured with regards to general liability. rCDTICIrATC Unl 1111=0 rAklrC1 I ATInM CITYFT5 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 Division PO BOX 580 Fort Collins, CO 80522 AUTHORIZED REPRESENTATIVE Karen E. Siwek, CPA ACORD 25 (2016/03) © 1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD NOTEPAD alm2s ALM2S-1 PAGE 2 INSUREDS NAME OP ID: B3 Date 03/26/2019 When required by written contract the following applies: Blanket Additional Insured BP 0451 Primary and Non -Contributory BP 1488 Blanket Waiver of Subrogation BP 0497 Additional Insured - State or Governmental Agency or Subdivision or Political Subdivision - Permits or Authorization Relating to Premises BP 0407 Blanket Additional Insured - Owners. Lessees or Contractors with Additional Insured Requirements for Parties in Construction Contract - BP 0451 Automobile - Blanket Additional Insured CA 7078 Blanket Waiver of Subrogation CA 0444 Umbrella - Following Form Workers Compensation - Blanket Waiver of Subrogation 359-B