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Home My WebLink About608057 GOLD STAR CONCRETE INC - INSURANCE CERTIFICATE (7)�� ® DATE (MM/DD/YYYY) A C CERTIFICATE OF LIABILITY INSURANCE 4/8/2019 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 NAMEp_-.. „SCOtt Anderson Commercial Risk Solutions PHONE - - 6600 E Hampden Ave Ste 200 E MAIL • 303-996 7801 arc No): 303-757-7719 Denver CO 80224 ADD ESS: sanderson crsdenver.com INSURED Gold Star Concrete, Inc. 119 Muriel Dr. Northglenn CO 80233 GOLST-2 INSURER(S) AFFORDING COVERAGE A: Employers Mutual Casualty Co. B_ Pinnacol Assurance INSURER E INSURER F : 0Cl/ICI(1N WIMARFR. NAIC # 21415 4119C 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. _..._ —PT--- INBR +— — — i�A6t5L)$t� POLICY EFF POLICY EX LIMITS LTR TYPE OF INSURANCE POLICY NUMBER MMfDD! MM/DD/YY A X COMMERCIAL GENERAL LIABILITY Y 5XB6615 5/5/2018 5/6/2019 EACH OCCURRENCE _ $ 1,000,000 MME ENTE6 PR MIS Ea-gqpurrenre $ 500,000 f CLAIMS -MADE OCCUR `� MED EXP _erson) _$(AAone� PERSONAL & ADV INJURY $1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE_ _ $2,000,000 v PRO- C LCC PRCTSCOMP/OPGG POLICY PRODUCTS A $ 2,000,000 —X� _.-- --. ___1 JECT -- -- OTHER: A AUTOMOBILE LIABILITY Y 5X8W15 5/6/2016 5/6/2019 COMBINED SINGLE LIMIT _ E i en — $1,000,000 BODILY INJURY (Per person) $ X ANY AUTO BODILY INJURY (Per accident) — -- $ OWNED SCHEDULED AUTOS ONLY AUTOS X HIRED NON -OWNED N PROPERTY DAMAGE $ AUTOS ONLY AUTOS ONLY P rcI en _ $ A X UMBRELLA LIAB X OCCUR 5XBB515 5/6/2018 516F2019 EACHOCCURRENCE $4,000,000 AGGREGATE $4,000,000� EXCESS LIAB CLAIMS -MADE DED RETENTION $ 11/1/2018 11/1/2019 �RH g WORKERS COMPENSATION Y 4187477 ,X� $TAT IW E AND EMPLOYERS' LIABILITY Y / N ANYPROPRIETOR/PARTNEFL'EXECUTIVE Y • I E.L. EACH ACCIDENT $ 500,000 --- —� E.L. DISEASE - EA EMPLOYEE OFFICER/MEMBER EXCLUDED? I (Mandatory In NH) N / A I $ 500,000 If yes. describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT $ 500,000 I � j DESCRIPTION OF OPERATIONS i LOCATIONS; VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached it 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. CERTIFICATE HOLDER L'All"'cr-L-AHull - 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 V lytRf-ZU75 AGVtSU l.VF11'VIIFI l wrv. Au rlynrs re5el VCu. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD 2 of 2 3967