HomeMy WebLinkAbout429371 HILLEN CORPORATION - INSURANCE CERTIFICATE (2)AC ORa� CERTIFICATE OF LIABILITY INSURANCE
DATE (MM/2019 Y)
03/19/019
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 Leigh Pullen
NAME:
Moody Insurance Agency, Inc.
PHONE (303) 824-6600 FAX (303) 370-0118
/C No Ext : A/C, No):
(A/C,
E-MAIL leigh.pullen@moodyins.com
ADDRESS:
8055 East Tufts Avenue
INSURER(S) AFFORDING COVERAGE
NAIC #
Suite 1000
INSURER A: PinnacolAssurance
41190
Denver CO 80237
INSURED
INSURER B :
INSURER C :
William D Hillen, A Corp.
INSURER D :
dba Hillen Corp
INSURER E :
7600 Dahlia Street
INSURER F :
Commerce City CO 80022
COVERAGES CERTIFICATE NUMBER: 19/20 WC REVISION NUMBER:
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FORTH E POLICY PERIOD
INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
CERTIFICATE MAYBE 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
INSD
WVD
POLICY NUMBER
MM/DD/YYYY
MM DD/YYYY
LIMITS
COMMERCIAL GENERAL LIABILITY
EACH OCCURRENCE
$
A A
CLAIMS -MADE OCCUR
PREMISES Ea occurrence
$
MED EXP (Any one person)
$
PERSONAL & ADV INJURY
$
N
GEN'LAGGREGATE LIMITAPPLIES PER:
GENERAL AGGREGATE
$
PRODUCTS - COMP/OPAGG
$
PRO
POLICY ❑ JECT ElLOC
$
OTHER:
AUTOMOBILE LIABILITY
COMBINED SINGLE LIMIT
Ea accident
$
BODILY INJURY (Per person)
$
ANYAUTO
OWNED SCHEDULED
AUTOS ONLY AUTOS
N
BODILY INJURY (Per accident)
$
PROPERTY DAMAGE
ter accident
$
HIRED NON -OWNED
AUTOS ONLY AUTOS ONLY
$
UMBRELLA LIAB
OCCUR
EACH OCCURRENCE
$
AGGREGATE
$
EXCESS LIAB
CLAIMS -MADE
DED I I RETENTION $
$
A
WORKERS COMPENSATION
AND EMPLOYERS' LIABILITY Y / N
ANY PROPRIETOR/PARTNER/EXECUTIVE
OFFICER/MEMBER EXCLUDED? �
(Mandatory in NH)
NIA
3091443
04/01/2019
04/01/2020
X STATUTE ORH
E.L. EACH ACCIDENT
1,000,000
$
E.L. DISEASE - EA EMPLOYEE
$ 1,000,000
E.L. DISEASE - POLICY LIMIT
1,000,000
$
If yes, describe under
DESCRIPTION OF OPERATIONS below
DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required)
Worker's Compensation:
359-B From Attached Includes Blanket Waiver of Subrogation. Status applies when required by written contract.
IMPORTANT:
The policy forms referenced will be sent via email only. To obtain copies, please send your request with the email address to certrequest@moodyins.com.
CFRTIFICATF Hni r1FR CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
The City of Fort Collins Purchasing Department
ACCORDANCE WITH THE POLICY PROVISIONS.
PO Box 580
AUTHORIZED REPRESENTATIVE
Fort Collins CO 80522,u
@ 1988-2015 ACORD CORPORATION. All rights reserved.
ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD