HomeMy WebLinkAboutTRINET HR III-A INC - INSURANCE CERTIFICATE1'3-ONE
oRO� CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DDIYYYY)
6/24/2019
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
Commercial Lines - (305) 443-4886
USI Insurance Services LLC
2601 South Bayshore Drive, Suite 1600
Coconut Grove, FL 33133
Risk Management Department
U: 866-443-8489 1a . Nel_ 800-889-0021
ACE American Insurance Company 1 22667
INSURED INSURER B:
TriNet HR III -A, Inc.
INSURER C :
L/C/F Masabi LLC
INSURER D: _
9000 Town Center Parkway INSURER E:
Bradenton, FL 34202 INSURER F:
COVERAGES CERTIFICATE NUMBER: 14338877 REVISION NUMBER: See below
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.
LTR
LTR
TYPE OF INSURANCE
ADOL
SUER
POLICY NUMBER
POLICY EFF
fMMtDDfYYYYI
POLICY EXP
(MM/DDIYYYYILIMITS
COMMERCIAL GENERAL LIABILITY
EACH OCCURRENCE
$
-DAWKGM RENTED
PREMISES a occurrence
$
CLAIMS -MADE OCCUR
MED EXP (Any one person)
$
PERSONAL iL ADV INJURY
$
GEN'L
AGGREGATE LIMIT APPLIES PER:
o
POLICY JEPRCT E-1 LOC
GENERAL AGGREGATE
$
PRODUCTB- COMP(OP AGG
$
$
OTHER:
AUTOMOBILE
LABILITY
COMBINED SINGLE LIMIT
Ea accident
$
BODILY INJURY Per person)
$
ANY AUTO
OWNED SCHEDULED
AUTOS ONLY AUTOS
BODILY INJURY )
(Per accident)
$
HIRED NON -OWNED
AUTOS ONLY AUTOS ONLY
PROPERTY DAMAGE
Per aCGdent
$
UMBRELLA LIAR
OCCUR
EACH OCCURRENCE
$
AGGREGATE
$
EXCESS UAe
CLAIM%ADE
DED I RETENTIONS
$
A
WORKERS COMPENSATION
AND EMPLOYERS'LIABILITY YIN WLR_C66247272
ANYPROPRIETOR/PARTNER/EXECUTIVE
MI OFFICEREMBER EXCLUDED? C NIA
7/1/2019
7/1/2020
X STATUTE ERH
E.L. EACH ACCIDENT
2,000.000
$
E.L. DISEASE- EA EMPLOYEE
S 2,000,000
(Mandatory in NH)
if ye9 describe under
DESCRIPTION OF OPERATIONS below
E.L. DISEASE - POLICY LIMIT
S 2,000,000
1
1
1
1
T
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101. Additional Remarks Schedule, may be attached if more space is required)
Workers' Compensation coverage is limited to worksite employees of Masabi LLC through a co -employment agreement with TriNet HR III -A, Inc.
City of Fort Collins SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
215 N Mason St, PO BOX 580 ACCORDANCE WITH THE POLICY PROVISIONS.
Fort Collins, CO 80524
AUTHORIZED REPRESENTATIVE /^^
I ne Avwmw name ango are regrea s OTCV 101CO
o logo marKAUhtL1 966-25 ACORD CORPORATION. All rights reserved.
ACORD 25 (2016/03) 11 11 11111 � � 1111111111 11IE 111111111111111111111111111
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