HomeMy WebLinkAbout127137 LA WOODWORKS INC - INSURANCE CERTIFICATE (3)A� 6r CERTIFICATE OF LIABILITY INSURANCE DA6�l�ol oYY)
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THIS CERTIFICATE IS ISSUED AS A MATTER -OF INFORMATION ONLY AND CONFERS NO RIGHTS UonU-TU= rrctannretc ua;•-r+�e-
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVE
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THI in order to provide this document
REPRESENT
OR
ND THE CERTIFICATE
IMPORTANT.AIf the certificate holder is an ADDITIONAL INSURED,
thHOLDER.
ED, the policjf(ies) must be endoreed. t0 y0U more QUICkIY, please provide
the terns and conditions of the policy, certain policies may require an endorsement A statement on me with a valid e-mail address.
certificate holder in lieu of such endorsement(s). Thank you!
PRODUCER -.. _- -_ -..--_ .NAME:. Pam Knespel -
Ewing -Leavitt Insurance Agency, Inc. PHONE EtI., (970) 679-7355 Al NO; 064.239.2119
4090 Clydesdale Parkway E41AIL ae-knespel(ileavitt.com
Suite 101 .INSURE S)-AFFORDNG COVERAGE .NAIC.II
Loveland CO 80538 WSURERA:Acuity, A Mutual Insurance _Company 14184
INSURED INSURER B:Pinnacol Assurance 41190
LA Woodworks Inc.. INSURERC:-
4476 Bents Drive INSURER D.: _-- -- -
INSURERF:
Windsor CO 80550 INSURER F:
COVERAGES CERTIFICATE NUMBER--L206105424 REVISION NUMBER:
THIS IS TO CERTIFY THAT THE.. POLICIES OF INSURANCE.USTED BELOW
HAVE BEEN ISSUED TOTHE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION
OF ANY CONTRACTOR OTHER DOCUMENT NTH RESPECTTO 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 SHOWJN
MAY HAVE BEEN REDUCED BY PAID CLAIMS.
INSR
LTR
TYPE OF INSURAN
ADDLISUBRI
POILICY
NUMBER
MOUMIDD/YYYY
MMMOIYYYY
LIMITS
X
COMMERCIAL GENERAL LIABILITY
EACH OCCURRENCE
$ 1,000,000
A
CLAIMS -MADE OCCUR
DAMAGE TO 17ERT915-
PREMISES Ea occurrence
$ 500, 000
X
MED. EXP A one person)$
10,000
Blkt Additional Insured
X
Z46492
6/1/2020
6/1/2021
X
Blkt Waiver of Subrogation
PERSONAL BADV INJURY
$ 1,000,000
GENT AGGREGATE LIMIT APPLIES PER:
GENERAL AGGREGATE
$ 2.,000;000
POLICY a PRO- LOC
PROOUCT3-COMPIOP AGG
$ 2,000;000
$
OTHER:
AUTOMOBILE LIABILITY
COMBINED SINGLE LIMA
Ea accident)
$ 1,000,000
BODILY INJURY (Per person)
$
A
j;K ANY AUTO
ALL OWNED SCHEDULEDz46492
AUTOS -- AUTOSX
6/1/2020
6/1/2021
BODILV INJURV (Peracddem)
$
PROPERTY DAMAGE
Per-accidentSWAMI
$
NON-0WNED
HIRED AUTOS XAUTOS
8 _
Insured X I BIkt yMS
X
UMBRELLA LIAR
X
OCCUR
EACH OCCURRENCE
E - .5 000000.
AGGREGATE.
$. .5 000,000.
A
EXCESS LIAR
.CLAIMS -MADE.
DED X, RETEMION $ 0
§ -
X
Z46492.
6/1/2020
--
6/l/2021
-
WORKERS COMPENSATION
AND EMPLOYERS' LIABILITY 1, I N
Blkt Waiver
of Subxo. Incl.
X PER"
STAT TE
TOR-
R
B
ANY PROPRIETORIPARTNERIEXECUTIVE
OFFICERIMEMBER EXCLUDED? N❑
(Mandatory In NH)
NIA
4148953
6/1/2020
6/1/2021
E.L. EACH ACCIDENT
$ 1 ODO 000
E.L. DISEASE - EA EMPLOYEE
$ 1,000,000
If yea, describe wider- -
DESCRIPTION OF.OPERATIONS .below.
_-_
__
_ ___
,.. _. ._ __... __
__. _
E.L.DISEASE- POI ICY. LIMIT
$ 1,000,000
A
Installation Floater
Z46492
6/1/2020
6/1/2021
Temporary Storage$1.000 Dad $1,000,000
O PTION OFb ERATONS / LOCATIONS 1 VEHICLES A,CORD 101.Addalona�rnar6
RE: Utilities Service Center. Project is 7157. SAP
Schedule, my in ffifached I more space Is required)
Mountain States LLC, City of Fort Collins and others as
required contract are named additional insured
.regards work performed by the insured on this project.
additional insureds listed above as regards the
on the General Liability and Auto Liability policies as
A waiver of .subrogation applies in favor of the
General. Liability, Auto Liability and Workers'
Compensation policies.
CERTIFICATE HOLDER I CANCELLATION
SHOULD ANY OF THE ABOVEMESCRIBED POLICIES BE CANCELLED BEFORE.
City Of Fort Collins
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
PO Box 580
ACCOROANCE'im THE POLICY PROVISIONS.
Fort Collins, CO 80522
AUTHORIZED REPRESENTATNE
Pam Knespel/PAKNES J 1pr,Q
W INOD-LUT4 AVUKU 1-UKt UKAI IU1V_. All rlgrls reserveo.
ACORD 25 (2014101) The ACORD name and logo are registered marks of ACORD
INS025 (201401)