HomeMy WebLinkAboutBLACK TIMBER BUILDERS LLC - INSURANCE CERTIFICATE (4)ACOR 1 0
`� CERTIFICATE OF LIABILITY INSURANCE
DATE (MMIDD/YYYY)
,,,,,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
Madison Insurance Group
600 South Cherry St, Ste 900
Denver CO 80246
LUNIAUI
NAME: Paula Blohm
H N 3033220800 wcFAX,No: 3033220874
A/C No Ext
ADDRESS: pblohm@madisoninstuance.net
INSURER(S) AFFORDING COVERAGE
NAIC #
INSURER A : PINNACOL ASSURANCE
41190
INSURED
Black Timber Builders, LLC
641 Whedbee Street
Fort Collins CO 80524
INSURER B : CLEAR BLUE SPECIALTY INSURANCE CO
INSURER C :
INSURER D :
INSURER E :
INSURER F :
r-nVFRAr.Fc rFRTIFIrATF Nt1MRFR- 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.
INSIR LTR
TYPE OF INSURANCE
INSD
WVD
POLICY NUMBER
MMIDD
MMIDDIYYYY
LIMITS
B
x
COMMERCIAL GENERAL LIABILITY
CLAIMS -MADE Fx_� OCCUR
103 GL0014825-02
07/12/2019
07/12/2020
EACH OCCURRENCE
$ 1,000,000
PREMISES (Ea occurrence)
$ 100,000
MED EXP (Any one person)
$ 5,000
PERSONAL SADVINJURY
$ 1,000,000
GEN'L AGGREGATE LIMIT APPLIES PER.
-
P JECT LOC
POLICY PROEl
OTHER:
GENERAL AGGREGATE
$ 2,000,000
PRODUCTS -COMP/OP AGG
$ 2,000,000
$
AUTOMOBILE LIABILITY
ANY AUTO
OWNED SCHEDULED
AUTOS ONLY AUTOS
HIRED NON -OWNED
AUTOS ONLY AUTOS ONLY
(Ea accident)
$
BODILY INJURY (Per person)
$
BODILY INJURY (Per accident)
$
FKUVtK I Y UAMAUL
(Per accident)
$
UMBRELLA LIAB
EXCESS LIAB
OCCUR
CLAIMS -MADE
EACH OCCURRENCE
$
AGGREGATE
$
DED
RETENTION $
$
A
ORKERS COMPENSATION
ND EMPLOYERS' LIABILITY
ANY PROPRIETORIPARTNEX
FFICER/MEMBEREXCLUDR)E ECUTIVEY❑
Mandatory in NFi)
tt yes. describe under
ESCRIPTION OF OPERATIONS belowI
NIA
4190143
03/01/2019
03/01/2020
STATUTE ER "
E.L. EACH ACCIDENT
$ 100,000
E.L. DISEASE -EA EMPLOYEE
$ 100,000
E.L. DISEASE - POLICY LIMIT
$ 500,000
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached R more space is required)
The 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
S 1p,r).n.nn )aw�N�4
V 1988-LU15 AGURD GURF'UHA I IUN. All ngnts reServea.
ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD