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HomeMy WebLinkAbout608057 GOLD STAR CONCRETE INC - INSURANCE CERTIFICATE (3)DATE (MM/DD.YYYY) AFRO® CERTIFICATE OF LIABILITY INSURANCE 5/3/2019 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 Commercial Risk Solutions NAME: Scott Anderson, CIC _ 6600 E Hampden Ave Ste 200 PHONE E,tl- 303-996-7833 me No: 303 757-7719 Denver CO 80224 ADDRESS: sandersonLDcrsdenver.com INSURED Gold Star Concrete, Inc. 119 Muriel Dr. Northglenn CO 80233 INSURERS) AFFORDING COVERAGE NAIC # INSURER A: Employers Mutual Casualty Co. 21415 GOLST-2 INSURER s : Pinnacol Assurance 41190 INSURER-C INSURER D : INSURER E : CAVFRAGFS CFRTIFICATF NIIMRFR-77z01aoza RRVIQlnN 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. ILTR ' TYPE OF INSURANCE ADDL,$Ubfi POLICY NUMBER MMLDDIYYYY MM pD/YYYY LIMITS A X COMMERCIAL GENERAL LIABILITY I Y 5X86615 5/6/2019 5/6/2020 1 EACH OCCURRENCE $1,000,000 CLAIMS -MADE � OCCUR `01I 1���i� t �-_.__.. _ _ �jiP �MIS�Srren�eZ $500,000 �- MED EXP (Any one person) - $ 10,000 _ PERSONAL & ADV INJURY $1,000,00o GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 - POLICY �� jRE . CT LOC _. PRODUCTS - COMP/OP AGG $ 2,000,000 _ OTHER: $ A AUTOMOBILE LIABILITY Y 5XBN15 5/6/2019 5/6/2020 COMBINED SINGLE LIMIT FiLa cc id e n Q_..___-.-- $1,OD0,000 BODILY INJURY (Per person) $ X ANY AUTO OWNED SCHEDULED AUTOS ONLY AUTOS I BODILY INJURY (Per accident) $ X HIRED X PROPERTY DAMAQE $ AU OS ONLY AUTOS ONLY I $ A X UMBRELLA LIAR OCCUR 5X86615 5/6/2019 5/6/2020 EACH OCCURRENCE $ 4,000,000 $ 4,000,000 EXCESS UAB CLAIMS -MADE AGGREGATE DED RETENTION $ $ B Y 4187477 11/1/2018 11/1/2019 IX` STATUTE ERH AND EMWORKERS PLOYERS' L ABILITY Y r N E.L. EACH ACCIDENT $ 500,000 ANYPROPRIETORiPARTNERJEXECUTIVE OFFICER;MEMBEREXCLUDED? a N / A E.L. DISEASE - EA EMPLOYEE — --- $ 500,000 (Mandatory In NH) If yes. describe under ---...... _-- _..._.... _,...._._ —._ _.._____..._ .._..---_..._._.... DESCRIPTION OF OPERATIONS below E.L DISEASE - POLICY LIMIT $ 500,000 A Leased 8 Rented SX88815 5/6/2019 5/6/2020 Limit 25,000 f Equipment Ded 500 DESCRIPTION OF OPERATIONS) LOCATIONS i VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space Is required) City of Fort Collins is included as additional insured for ongoing and completed operations on the General Liability and included as additional insured on the Auto Liability with respect to operations of the named insured for the certificate holder as required by written contract. Worker Compensation coverage includes a waiver of subrogation .General Liability policy has been endorsed to provide 30 days notice of cancellation except 10-day notice for non-payment of premium. All policy terms, conditions and exclusions apply. ULK I It-ICA 1 t: MULUIZH CANCtLLATION City of Fort Collins P.O. Box 580 Fort Collins CO 80522 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 / © 1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD 2 of 2 2542