HomeMy WebLinkAboutGOLD STAR CONCRETE INC - INSURANCE CERTIFICATEACOR& CERTIFICATE OF LIABILITY INSURANCE
DATE(MM/DD/YYYY)
10/4/201 s
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(les) 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
Commercial Risk Solutions
6600 E Hampden Ave Ste,200
Denver CO 80224
S
-NAME: colt Anderson CIC
PHONE AX
363-996-7833 tPAIC.No: 303-757-7719
-ADDRESS: sanderson arsdenvercom
INSURE S AFFORDING COVERAGE
NAIL C
INSURER A! Employers Mutual Casualty Co.
21415
INSURED - 'GOLST-2
Gold Star Concrete, Inc.
119 Muriel Dr.
.:INSURER 13: Plnnacal Assurance
41190
INsuRERc:
INSURER o :
Northglenn CO 80233
�INSURER'E:
-
INSURER F:
COVERAGES CERTIFICATE NUMBER:329724314 REVISION NUSARFA-
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
CTR
TYPE OFINSUAANCE
ADIDLISLIURI-
I
rY p
POLICY NUMBER
POLIpCY EFF
MMNWYV.
POLICcY EXP
MM4)CIYYY
.
LIMITS
A
XGOOMMERCIAL
GENERAL LIABILITY -
CLAIMS -MADE � OCCUR
Y
SX86615
5162019
5/612020
EACHOCCURRENCE
$1.000,000
ENIED
PREMISES ocanrence
E
s500.000
MED EXP (Any .oneperson)
$10,000
PERSONAL &ADV INJURY
$1,060,000
GEN'L
AGGREGATE LIMIT APPLIES PER:
POLICY IK JECT IJ LOC
OTHER:
GENERAL AGGREGATE
$2,000,000
PRODUCTS -.COMPiop,Ago.
$2,000.000
$
A
---
AUTON061LELIABILITY
-
ANY AUTO
A OED 1:1AUTOSULEDBODILY
AUTOS ONLY HIRED x I A OS ONLY
I
Y
SX86615
-
5162019
5/6/2020
OM
BIN SINGLE LIMIT a acpden
$1,000,000
BODILY INJURY(Perperson)
$
Ix
INJURY (Poracciden0
S
Pe�acddantDAMAGE
$
S
A
X
UMBRELLAUAB
EXCESS UAB
I X OCCUR
CLAIMS -MADE
5XB6815
5/6/2019,
5/612020,
EACHOCCURRENCE
$4,000,000
AGGREGATE
S4';000,000
DED RETENTIONS_._.-
B
WORKERS COMPENSATION
AND EMPLOYERS' LIABILITY YIN
ANYPROPRIETOR/PARTNEPJEXECUTIVE O
OFFICERIMEMSEREXCLUDED?
(Mandatory In NFO
It yes�descrfbe under —
DESCRIPTION.OF OPERATIONS below
NIA
Y
4187477
-
-
11/12019
11/12020
X g7ATUTE.ER..
E.L. EACH ACCIDENT
$ 500,000
E.L. DISEASE -EA EMPLOYEE
$500:000
( E.L. DISEASE- POLICY LIMIT
$ 500,000
A
Leased M ented
SX86615
6/6/2019
5/62020
Lid
250 00
DESCRIPTION OF OPERATIONS / LOCATIONS /VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached If more apace 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 ofpremium.
All 'policy terms, conditions and exclusions apply.
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
City of Fort Collins
P.O. Box 580 AUTHQRIZEO REPRESENTATIVE
Fort Collins CO 80522 /1
E:
ACORD 25 (2016103) The ACORD name and logo are registered marks of ACORD
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