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HomeMy WebLinkAboutROLEXIS INC DBA TEAM SPORT PHOTOS - INSURANCE CERTIFICATE (3)AC"R,[7® CERTIFICATE OF LIABILITY INSURANCE ��- DATE2019 mYY) oale/o19 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 Michele Regis CONTACT NAME: Sentry Customer Service PHONE FAX A C o Ext: 800-473-6879 A/C N • 600-514-7191 EMAIL ADDRESS: businessproducts directitsen .com INSURER(S) AFFORDING COVERAGE NAIC p INSURER A: Sentry Insurance a Mutual Company 24988 INSURED INSURER 8 : Rolexis Inc 11880 Upham St Unit A INSURER C INSURER D : Broomfield, CO 80020-2786 INSURER E : INSURER F : COVERAGES CERTIFICATE NUMBER: 940855 REVISION NUMBER: 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 LTR TYPE OF INSURANCE ADDL INSR SUBR WVD POLICY NUMBER POLICY EFF MM/DD/Y POLICY EXP MM/DD/Y LIMITS q X BUSINESSOWNERS LIABILITY CLAIMS -MADE AI OCCUR X 4999863001 01/01/2019 01/01/2020 EACH OCCURRENCE $ 1,000,000 DAMAGE TOR ENTED PREMISES Ea occurrence S 300,000 MED EXP (Any one person) $ 10,000 PERSONAL & ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: POLICY PRO LOC JECT OTHER: GENERAL AGGREGATE S 3,000,000 X PRODUCTS -COMP/OP AGG $ 3,000,000 $ A AUTOMOBILE —1 LIABILITY ANY AUTO OWNED SCHEDULED AUTOS ONLY AUTOS HIRED X NON -OWNED AUTOS ONLY AUTOS ONLY X 4999863001 01/01/2019 01/01/2020 C(a arB,cl'd SINGLE LIMIT $ 1,000,000 BODILY INJURY (Per person) $ X BODILY INJURY (Per accident) $ PROPERTY DAMAGE Per accident)$ UMBRELLA LIAR EXCESS LIAR H OCCUR CLAIMS -MADE EACH OCCURRENCE S AGGREGATE $ DED I I RETENTION S S WORKERS COMPENSATION AND EMPLOYERS' LIABILITY y / N ANY PROPRIETOR/PARTNER/EXECUTIVE ❑ OFFICER/MEMBER EXCLUDED? (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below N / A PER pTH- STATUTE ER E.L. EACH ACCIDENT $ E.L. DISEASE - EA EMPLOYEE $ E.L. DISEASE - POLICY LIMIT $ DESCRIPTION OF OPERATIONS /LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached it more space is required) Refer to attached CERTIFICATE HOLDER CANCELLATION City of Fort Collins SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE 215 N Mason St2nd FI THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Po Box 580 ACCORDANCE WITH THE POLICY PROVISIONS. Fort Collins, CO 80522-0580 AUTHORIZED REPRESENTATIVE/1� ACORD 25 (2016/03) 4999863 Sentry Insurance a Mutual Company 3 00003 0000000464 19108 0 N Page 1 of 2 01988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD 04/18/2019 CDC9062C-3424-4103-8F55-514D4576EE5F 0027020044349736250280522058080 AGENCY CUSTOMER ID: )000=8793 AC"J?"" LOC q: — ADDITIONAL REMARKS SCHEDULE Page 2 of 2 AGENCY Michele Regis NAMED INSURED Rolexis Inc POLICY NUMBER 4999863001 CARRIER Sentry Insurance a Mutual Company NAIC CODE 24986 EFFECTIVE DATE: 01/01/2019 ADDITIONAL REMARKS THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, FORM NUMBER: ACORD 25 FORM TITLE: Certificate of Liability Insurance Businessowners Job: Going Onsite To Take Photos ACORD 101 (2008/01) 4999863 Sentry Insurance a Mutual Company © 2008 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD 04/18/2019 POLICY NUMBER: 4999863001 BUSINESSOWNERS BP 04 50 07 13 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - OWNERS, LESSEES OR CONTRACTORS - SCHEDULED PERSON OR ORGANIZATION This endorsement modifies insurance provided under the following: BUSINESSOWNERS COVERAGE FORM SCHEDULE Name Of Additional Insured Person(s) Or Organization(s) Location(s) Of Covered Operations City of Fort Collins City of Fort Collins 215 N Mason ST 2nd FL PO Box 580 Fort Collins, CO 80522 Description: City of Fort Collins Information required to complete this Schedule if not shown above will be shown in the Declarations. Section II - Liability is amended as follows. - A. The following is added to Paragraph C. Who Is An Insured: 3. Any person(s) or organization(s) shown in the Schedule is also an additional insured, but only with respect to liability for "bodily injury", "property damage" or "personal and advertising injury" caused, in whole or in part, by: a. Your acts or omissions; or b. The acts or omissions of those acting on your behalf; in the performance of your ongoing operations for the additional insured(s) at the location(s) designated above. However: a. The insurance afforded to such additional insured only applies to the extent permitted by law; and B. With respect to the insurance afforded to these additional insureds, the following additional exclusions apply: This insurance does not apply to "bodily injury" or "property damage" occurring after: 1. All work, including materials, parts or equipment furnished in connection with such work, on the project (other than service, maintenance or repairs) to be performed by or on behalf of the additional insured(s) at the location of the covered operations has been completed; or 2. That portion of "your work" out of which the injury or damage arises has been put to its intended use by any person or organization other than another contractor or subcontractor engaged in performing operations for a principal as a part of the same project. b. If coverage provided to the additional insured is required by a contract or agreement, the insurance afforded to such additional insured will not be broader than that which you are required by the contract or agreement to provide for such additional insured. Change effective 04/17/2019 BP 04 50 07 13 OO Insurance Services Office, Inc., 2012 Pagel of 2 4999863 04/18/2019 Sentry Insurance a Mutual Company 5 00003 0000000464 19108 0 N 3D3AOC6F-D66E-4589-A762-CF86ESOF69E0 0027020044349736250580522058080 C. With respect to the insurance afforded to these additional insureds, the following is added to Paragraph D. Liability And Medical Expenses Limits Of Insurance: If coverage provided to the additional insured is required by a contract or agreement, the most we will pay on behalf of the additional insured is the amount of insurance: 1. Required by the contract or agreement; or 2. Available under the applicable Limits Of Insurance shown in the Declarations; whichever is less. This endorsement shall not increase the applicable Limits Of Insurance shown in the Declarations. Change effective 04/17/2019 Page 2 of 2 © Insurance Services Office, Inc., 2012 4999863 Sentry Insuiance a Mutual Company BP04500713 04/18/2019