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�C� DATE (MM/DDNYYY)
CERTIFICATE OF LIABILITY INSURANCE 02/20/2019
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:
Willis of Illinois, Inc.
c/o 26 Century Blvd PHONE 1-877-945-7376 FAX
ANo: 1-888-467-2378
P.O. Box 305191 ADDRESS: certificates@willis.com
Nashville, TN 372305191 USA INSURER(S) AFFORDING COVERAGE NAICp
INSURERA: XL Insurance America Inc 24554
INSURED INSURERB: Navigators Insurance Company 42307
Convergent Technologies LLC #350 ------- -
Location #350 INSURER C : XL Specialty Insurance Company 37885
One Commerce Drive INSURER D'__
Schaumburg, IL 60173 USA
INSURER E
COVERAGES CERTIFICATE NUMBER! W10139234 RFVISInN NIIMRFR-
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.
M TYPE OF INSURANCE N Di
POLICY NUMBER Poum 6am LIMITS
X
I COMMERCIAL GENERAL LIABILITY
EACH OCCURRENCE
$ 11000,000
t—�
CLAIMS -MADE X OCCUR
-D MAGE TO RENTED
_PREMISE$_(E4
--
$ 300,000
A
MED EXP (Any one parson)
$ 10,000
Y
CGS 7409054 07 I03/01/2019103/01/20201
I PERSONAL RADVINJURY
$� 1,000,000
L AGGREGATE LIMIT APPLIES PER:
GEN
GENERAL AGGREGATE
$ 2,000,000
POLICY %t JE C LOC
j
PRODUCTS • COMPlOP A(3G
��
$ 2,000,000
$
OTHER:
AUTOMOBILE LIABILITY
COMBINEDSINGLE LIMIT
, $ 1,000,000
X ANY AUTO
BODILY INJURY (Per person)
$
A
OWNED SCHEDULED
AUTOHIRED S ONLY AUTOS
CAR 7400024 08 03/02/2019 03/01/2020
BODILY INJURY (Per accident)
$
X NON OWNED
-. -.----__
PROPERTY DAMAGE
$
AUTOS ONLY AUTOS ONLY
j
PSCs4@!St)
$
B
UMBRELLALIAB XIOCCUR
EACHOCCURRENCE
$ 4,000,000
X EXCESS UAB �' CLAIMS -MADE
C519KXC704521IV
03/01/2019:03/01/2020 AGGREGATE
$ 4, 000, 000
T
DED RETENTION
$
WORKERS COMPENSATION
iX
-
V SPTFT T
,00
$ 1, 000, 000
C ANYPRO
E.L. EACH ACCIDENT
MEMB REXC UDED?ECl171VE ❑
OPYPROM6TOR,P EXCLUDED? No
N/A
CWG 7400022 08 03/01/2019
(Mandatory In NH)
E.L. DISEASE. EA EMPLOYEE
$ 1,000,000
If yes, describe under
DESCRIPTION OF OPERATIONS below
E.L. DISEASE - POLICY LIMIT
_
$ 1, 000, 000
I
�I
I
DESCRIPTION OF OPERATIONS ! LOCATIONS VEHICLES (ACORD
101, Additional Remarks Schedule, may be attached if more space is required)
Re: Project #35OFNF074 / 10-01245 Eye Care
Center of Northern Colorado.
City of Fort Collins is included as an Additional Insured as respects to General Liability as required
by written
contract.
(:tH I It-IUA I r- ML)LUtH
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
City of Fort Collins AUTHORIZED REPRESENTATIVE
300 LaPorte Avenue c
Fort Collins, CO 80521 LuW/lU ew C '11Ar v
C 1988-2016 ACORD CORPORATION. All rights reserved.
ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD
sR 11): 17538364 BATCH: 1074505
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