HomeMy WebLinkAbout608057 GOLD STAR CONCRETE INC - INSURANCE CERTIFICATE (4)DATE (MWDD�YYYY)
ACOR" 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 Anderson, CIC
NAME: Scott
Commercial Risk Solutions PHONE FAX
6600 E Hampden Ave Ste 200 : 303-996-7833 A/c No: 303-757-7719
Denver CO 80224 E-MAIL : Sanderson crsdenver.com
INSURED GOLST-2
Gold Star Concrete, Inc.
119 Muriel Dr.
Northglenn CO 80233
INSURER(P)AFFORDING COVERAGE NAIC #
INSURER A Employers Mutual Casualty Co. 21415
lN9uR6R6: Pinnacol Assurance _ j 41190
INSURER E :
INSURER F :
COVERAGES CFRTIFICATE NIIMRER- 11AR31n7A7 RFVISION 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.
INSR TYPE OF INSURANCE -� - -ADD - - - -- POLICY EFF POLICY -
LTR POLICY NUMBER MM/pD/YYYYYYYI ' LIMITS
A
X COMMERCIAL GENERAL LIABILITY
5X86615
5/6/2019
5/6/2020 EACH OCCURRENCE
$1,000,0DO
—� ,CLAIMS -MADE OCCUR
PR MI$E $L@-ocQ4rr�n�q)_
$500,000 -
$10,000
1,000,000
_
_
MED EX_P (A� oneperson)
PERSONAL & ADV INJURY
GEN'L AGGREGATE LIMIT APPLIES PER:
$ 2,000,000
GENERAL AGGREGATE
POLICY _X E � LOC
PRODUCTS- COMP/OP AGG
__- —
$ 2,000,D00
$- --
' OTHER:
A
AUTOMOBILE LIABILITY
X ANY AUTO
5X66615
502019
11112020
COMBINED SINGLE LIMIT
BODILY INJURY (Per person)
$1.000,000
$
OWNED SCHEDULED
AUTOS ONLY AUTOS
BODILY INJURY (Per accident
_
X HIRED X NON -OWNED
AUTOS ONLY AUTOS ONLY
PROPERTY DAMAGE
$
$
A
X UMBRELLALIAB
X OCCUR
5XB6615 SW019
5/6/2020 EACH OCCURRENCE_
$4,000,D00
EXCESS LL4B
CLAIMS -MADE
I
AGGREGATE _ _ _
$ 4,000,000
DED ! RETENTION $
$
B
WORKERS COMPENSATION
AND EMPLOYERS' LIABILITY Y / N
ANYPROPRIETORiPARTNER/EXECUTIVE Y
(OFFICER/MEMBER EXCLUDED?
NIA
:
i
4187477 11/1/2018
11/1,2019 X I PTAT TE ORH
—
E.L.EACH ACCIDENT
— ----
I
$ 500 000 -- ----
1(Mandatory In NH)
E.L DISEASE EA EMPLOYEE
$ 5D0 ODO
'If yes, describe under
DESCRIPTION OF OPERATIONS below
__. .. __.._,._ _ ._....._ .. .__
E.L. DISEASE - POLICY LIMIT
—__ -... .......
$ 500.000
A Leased 8 Rented
Equipment
5X86615 5/6/2019 5/6/2020
Limit
Ded
25,000
500
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.
l•1=1 I I.1_l l3iNl!191: •f_1 C1P131qAfLll Lai
City of Fort Collins
Purchasing Department
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
OO 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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