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Home My WebLink AboutSURE SHOT DRILLING LLC - INSURANCE CERTIFICATEA� i CERTIFICATE OF LIABILITY INSURANCE DATE,MWD°"YY" 3/16/2020 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 pollcy(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 Ileu of such endorsements . PRODUCER IMA, Inc. - Colorado Division 1705 17th Street, Suite 100 Denver CO 80202 FA NAME, IMA Denver Team PHONE FAX • 303-534-4567 A/c No): . -MAIL _.. .. ..- ADDRESS: DenAccountTechs imaco .com INSURERS AFFORDING COVERAGE. NAIC 7 INSURER A: Valley Forge Insurance Co. 20508 INSURED � SF000D059887 INSURERS.: COntlneOtBl Insurance Company 3$269 Sure Shot Drilling, LLC P.O. Box 17886 INsuRERc: Navigators Specialty Insurance Company 36056 INSURERD: Pinnacol Assurance 41190 Denver CO 80217 INSURER E : INSURER F: rnvFRAnFR CERTIFICATE NUMRFR- 9n5RaA37n3 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 ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLLIICIIEAffffqgS. LIMITS SHOWN MAY HAVE BEEN REDUC�EyD BY PAID C�LLAffms. ILTR TYPE OFINSURANCE I POLICYNUMBER POLICY POU DIYYY LIMITS A X COMMERCIAL GENERAL UA13JUTY 6080483546 3/1/2020 3/1/2021 EACH OCCURRENCE $1,000,000 CLAIMS -MADE aOCCUR DAMAGE TO R PREMISESEaoccurrence $500.000 X MED EXP An one arson) $15,000 Cant Uab Ind X XCU Not Excluded PERSONAL & ADV INJURY $1.000,000 GEN'L AGGREGATE LIMIT APPLIES PER; GENERAL AGGREGATE $2,000,000 X POLICY A PRO. �LOC PRODUCTS-COMP/OP AGG $2,000,000 $ OTHER: B AUTOMOBILE LIABILITY 608,0483577 3/12020 311/2021 EnaodeDI)INGLE LIMIT $1,000,000 X ANY AUTO BODILY INJURY (Par person) $ OWNED SCHEDULED AUTOS ONLY AUTOS BODILY INJURY (Per accident) $ PROPERTY DAMAGE (Per accident) $ X HIRED X NON -OWNED AUTOS ONLY AUTOS ONLY _ B X UMBRELLA LIAB X OCCUR 6080483563 3/1/2020 X1/2021 EACH OCCURRENCE $5,000,000 AGGREGATE $5,000,000 EXCESS LIAS CLAIMS -MADE OED X I RETENTION$:in nnn $ O WORKERS COMPENSATION AND EMPLOYERS'UABILITY ANYPROPRIETOR/PARTNER/EXECLITIVE Ya. OFFICERMIEMBEREXCLUDED7 (Mandatory In NH) NIA 4215483 3/112020 311/2021 X AT TE ERH E.L. EACH ACCIDENT $1,000,000 E.L. DISEASE - EA EMPLOYEEI $1,000,000 II yes, describe under DESCRIPTION OF OPERATIONS. below E.L. DISEASE- POLICY LIMIT $ 1,000,000 C Excess Second Layer Coverage H020EXCZ04POJIC 3/112020 3/1/2021 Each Occurrence Aggregate $6,000,000 $6,000,000 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached If more spew Is requlned) Automobile Physical Damage Coverage: Policy #6080483577 Effective Dates: 03/01120-03/Ot)21 Insurer B: See Above $2,000 Comprehensive Deductible; $2,000 Collision Deductible Professional/Pollution Liabilib Coverage: Policy #MKLV4ENV102962 Effective Dates: 03/01/- l 01/21 Insurer: Markel - Evanston Ins. Co. $5,000,000 Each Claim Limit; $5,000,000 Shared Aggregate Limit; $10,000 SIR Deductible See Attached... CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN City Of Ft Collins ACCORDANCE WITH THE POLICY PROVISIONS. PO Box 580 AUTHORIZED R RESENTATIVE Fort Collins CO 80522-0580 USA ///��/V1 01988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD 2' of 31 1295 AGENCY CUSTOMER ID: SF0000059887 LOC #: A oRV ADDITIONAL REMARKS SCHEDULE Page 1 of 1 AGENCY IMA, Inc. - Colorado Division NAMED INSURED Sure Shot Drilling, LLC P.O. Box 17886 Denver CO 80217 POLICY NUMBER CARRIER NAIC CODE EFFECTIVE DATE: THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, FORM NUMBER: 25 FORM TITLE: CERTIFICATE OF LIABILITY INSURANCE Contractors Equipment Coverage: Policy #QT6606J780867TIL20 Effective Dates: 03/01/20-03101/21 Insurer: Travelers Prop. Casualty Co. of America $12,547,015 Unscheduled Equipment; $5,000 Deductible Leased and Rented Coverage: Policy-#QT6606J780867TIL20 Effective Dates: 03101/20-03/01121 Insurer: Travelers Prop. Casualty Co. of America $865,000 Limit; $5,000 Deductible RE: Contractor's License. City of Ft Collins is included as Additional Insured on the General, Automobile, and Umbrella Liability Policies if required by written contract or agreement and with respect to.work performed by Insured subject to the policy terms and conditions. A Waiver of Subrogation is provided in favor of Additional Insured on the General, Automobile, Umbrella Liability and Workers Compensation Policies if required by written contract or agreement and with respect to work performed by Insured subject to the policy terms and conditions. This Insurance is Primary and Non -Contributory on the General, Automobile and Umbrella Liability Policies subject to the policy terms and conditions. 2008 The ACORD name and logo are registered marks of ACORD All 3' of 31 1295