HomeMy WebLinkAbout608057 GOLD STAR CONCRETE INC - INSURANCE CERTIFICATE (8)ACoR& CERTIFICATE OF LIABILITY INSURANCE
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DATE IMMrDDNYYY)
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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 CERTIFICATEMOLDER.
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
Commercial Risk Solutions
5600. E Hampden Ave Ste 200
Denver CO 80224
NAME: ScottAnderson, CIC
PHONE AX
ry • 363-99677833 . __ _ Alc No : 303757-7719
ADDRESS: sanderson crsdenver.com
INSURER AFFORDING COVERAGE
NAiC a
INSURER A:'Employers MutualCasuaf Co.
21415
INSURED GOLST-2
Gold Star Concrete, Inc.
119 Muriel Dr.
INSURERS: Plnnacol Assurance
41.190
INSURERC:
INSURER D :
Northglenn CO 80233
INSURERE:
INSURER F'i
... .. - _.
COVERAGES CERTIFICATE NUMBER: 1263133196 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.
INSR
LTR
TYPE OF INSURANCE
ADDL
D
SUERPOLICCY
P000YNUMSER
EFF
MLOWAN'Y
POLICY EXP
MIDDIYY
ITS
A
X
COMMERC AL GENERAL LIABILITY
CLAIMS -MADE FKOCCUR
Y
5X8B615
51612019
5/612020
-EACH OCCURRENCE
$1.000,000
_
PREMISES Eaocwrronce
$500,000
MED EXP (Any one person)
$10,000
PERSONAL &ADV INJURY
$1,000,000
GEN'L AGGREGATE LIMIT APPLIES PER:
POLICY [K].,PIEOT = LOC
OTHER:
GENERAL AGGREGATE
$2,000,000
PRODUCTS - COMPIOP AGG
$2,000,000
$
A
ALIT
ONO BILEW1swery
ANY AUTO
OWNED SCHEDULED
AUTOS
AUTOS ONLYPX1
AUTOS.ONLV AUOTOS ONL�
5XB6615
5/612019
5/612020
EOMBINE�DISINGLE LIMIT
$1.000.000
X
BODILY INJURY (Per person)
$
BODILY INJURY (Pm accident)
$
X-
PerraccidonOAMAGE
$
A
X
UMBRELLA LIAB OCCUR
EXCESS LIAR IN CLAIMS -MADE
5X66615
5/612019
51612020
I
EACHOCCURRENCE
$4,000.000
AGGREGATE.
$4,000,000
DIED I I RETENTION i
I
Is
B
WORKERS COMPENSATION
AND EMPLOYERS'. LIABILITY
ANYPROPRIETOR/PARTNER/EXECUTIVE. YIN
OFFICERIMEMBEREXCLUDED?
(MandatoryIn NH)-
It yes, describe under
DESCRIPTION OF OPERATIONS loolow
N/A
4187477
1111/2019
1.1l1/2020
X STATUTE ER,
E.L. EACH ACCIDENT
$ 500;000
E.L. DISEASE- EA EMPLOYEE
$ 500,000
E.L. DISEASE - POLICY LIMIT
$ 500,000
A
Leased & Rented
Equipment
5XO6615
5/6Y2019
-
5/6/2020
Umk
Ded
25.000
500
DESCRIPTION OF OPERATIONS LOCATIONS I VEHICLES (ACORD 101. Additional. Remarks Schedule, may be attached it more space is required)
City of Fort Collins is included as additional insured on the General Liability, with respect to ongoing and completed operations of the named insured for the
certificate holder as required by written contract. All policy terms, conditions and exclusions apply.
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF -THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION_ DATE' THEREOF, NOTICE WILL BE DELIVERED IN
City Of Fort Collins
ACCORDANCE WITH THE POLICY PROVISIONS.
Purchasing Department
AUTHORIZED REPRESENTATIVE
P.O. Box.580
Fort Collins GO 80522
01988.2015 ACORD CORPORATION. All rights reserved.
ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD
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