HomeMy WebLinkAbout608057 GOLD STAR CONCRETE INC - INSURANCE CERTIFICATE (6)DATE (MM/DDIYYYY)
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
Commercial Risk Solutions NAME: Scott Anderson Clc
6600 E Hampden Ave Ste 200 PHONE 303-996-7833 a c No): 303-757-7719
Denver CO 80224 ADDRESS: sanderson0crsdenver.com
_ .INSURER S .AFFORDING COVERAGE NAIC #
_..._- _...-. ._... _..-_—..__._-..�.�_—..—__._NAI
INSURER A: Employers Mutual Casualty Co. 21415
INSURED GOLST-2 INSURERS: Pinnacol Assurance _ _ 41190
Gold Star Concrete, Inc.
119 Muriel Dr. JNSURERC: _
Northglenn CO 80233 INSURER0:
INSURER E :
INSURER F : �—
CnVFRAGFR RFRTIFICATF NIIMRFR.1"o na17R�) RFVICIAPJ 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 IA6DL;SUA POLICY EFF POLICY EXP UMW
LTR POLICY NUMBER MMIDD/YYYY M/DDiYYYY
A
X COMMERCIAL GENERAL LIABILITY
5XB5615
5/6/2019
5/6/2020 EACH OCCURRENCE
$1.000,000
- -_.-., —
X
._ OAT A6GL' -(YRrFiTEtS —
_..-
CLAIMS -MADE I I OCCUR
PR.EMI$ES LEa occurren_cet
$ 500,000
_$10_,000
MED EXP (Any one person)
PERSONAL 8 ADV INJURY
$1.000,000
GEN'L AGGREGATE LIMIT APPLIES PER:
$ 2,000,D00
GENERAL AGGREGATE
POLICY X PRO- �} LOC
PRODUCTS.COMP/OP AGG
_ ------
$ 2.000,000
_
OTHER:
�
$
A
AUTOMOBILE LIABILITY
5X86615
5/8/2019
5/6/2020
COMBINED SINGLE LIMIT
$1,000,000
BODILY INJURY (Per parson)
$
X ANY AUTO
OWNEDONLY AUTOS SCHEDULED
AUTOS
BODILY INJURY (Per accident)
$
X HIRED X NON -OWNED
___
PROPERTY DADAMAGE -
_-
$
AUTOS ONLY AUTOS ONLY
P r gQcidfLnjj.___,__
A
X UMBRELLA LIAB X OCCUR
5XS8615 1 5/6/2019 5/6/2020
EACH OCCURRENCE
$ 4 000 000
EXCESS LIAB 17 CLAIMS•MADE
$ 4 000 000
' AGGREGATE
DED I RETENTION $
$
B
WORKERS COMPENSATION
4187477 11/1/2018 11/1/2019
'X PER TH•
STATUTE EA
AND EMPLOYERS' LIABILITY YIN
-- _
E.L. EACH ACCIDENT
ANYPROPRIETOR/PARTNER''EXECUTIVE
5_00,_0_0_07y
OFFICERWEMBEREXCLUDED?
iN/A
_.-._.$_
(Mandatory In NH)
E.L. DISEASE EA EMPLOYEE!
$ 500,000
If yes. describe under
,f--__...—_-_.._.__.____._.____—._.._.__.___.__.
DESCRIPTION OF OPERATIONS below
E.L. DISEASE - POLICY LIMIT
$ 500,000
A
Leased 8 Rented
Equipment
5X86615 5/6/2019 5/6/2020 Limit 25,000
I
Ded 500
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.
FI I IFIL;A I t
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
P.O. Box 580 AUTHORIZED REPRESENTATIVE
Fort Collins CO 80522 AlAk I � �1/
C 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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