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HomeMy WebLinkAbout304997 BELFOR ENVIRONMENTAL INC - INSURANCE CERTIFICATE (7)A R ® CERTIFICATE OF LIABILITY INSURANCE DATE06M 9/D201) 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 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 Aon Risk Services Central, Inc. MI office CONTACT NAME PHONE(866) 2(FAACX (A/C. No. Ext): No.): (800) 363-0105 .Southfield E-MAIL ADDRESS: 3000 Town Center Suite 3000 INSURER(S) AFFORDING COVERAGE NAIC # Southfield Mi 48075 USA INSURED INSURER A: National Union Fire Ins Co of Pittsburgh 19445 Belfor Environmental, Inc. INSURER B: The Insurance Co of the State of PA 19429 5075 Kalamath Street Denver co 80221 USA INSURER C: INSURER D: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: 570058175460 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. Limits shown are as requested INSR LTR TYPE OF INSURANCE INSD WVO POLICY NUMBER MM/DD/YYYY MM DD/YYYY LIMITS A X COMMERCIAL GENERAL LIABILITY GL 1 1 1 1 EACH OCCURRENCE $2,000,000 SIR applies per policy terns & conditions DAMAGET RENTED $2,000,000 CLAIMS -MADE X❑ OCCUR PREMISES Ea occurrence MED EXP (Any one person) $10 , 000 PERSONAL &ADV INJURY $1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER. GENERAL AGGREGATE $4 , 000 , 000 POLICY M PRO FX] LOC PRODUCTS - COMP/OP AGG $4,000,000 JECT OTHER. A AUTOMOBILE LIABILITY CA-319-43-30 07ZO112015 07/01/2016 COMBINED SINGLE LIMIT Ea accident $2,000,000 BODILY INJURY ( Per person) X ANY AUTO BODILY INJURY (Per accident) ALL OWNED SCHEDULED X X AUTOS AUTOS PROPERTY DAMAGE X HIRED AUTOS X NON -OWNED (Per accident AUTOS X Coll Ded $1,000 X Comp Ded $1,000 UMBRELLA LIAR EACH OCCURRENCE AGGREGATE EXCESS LAB HOCCUR CLAIMS -MADE DED I RETENTION B WORKERS COMPENSATION AND wcol4267780 07/01/2015 07/01/2016 X( STATUTE EORH EMPLOYERS' LIABILITY YIN A05 E.L. EACH ACCIDENT $1 , 000 , O00 B ANY PROPRIETOR / PARTNER / EXECUTIVE WC014267783 07/O1/2015 07/O1/2016 OFFICER/MEMBEREXCLUDED? (Mandatory in NH) NIA CA E.L. DISEASE -EA EMPLOYEE $1 , 000 , 000 If yes, describe under DESCRIPTION OF OPERATIONS below EL. DISEASE -POLICY LIMIT $1 , 000 , 000 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) City of Fort Collins 'is included as Additional insured in accordance with the policy provisions of the General Liability and Automobile Liability policies. CERTIFICATE HOLDER CANCELLATION 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 AUTHORIZED REPRESENTATIVE Attn: Purchasing Division Po Box Fort Collinsli CO 80522 USA d 0 r` m O 0 Ln ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25 (2014/01) The ACORD name and logo are registered marks of ACORD AGENCY CUSTOMER ID: 570000005415 LOC #: 4 ADDITIONAL REMARKS SCHEDULE Page _ of _ AGENCY Aon rusk services central, inc. NAMEDINSURED Belfor Environmental, inc. POLICY NUMBER See Certificate Number: 570058175460 CARRIER see Certificate Number: 570058175460 NAIC CODE EFFECTIVE DATE. ADDITIONAL REMARKS THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, FORM NUMBER: ACORD 25 FORM TITLE: Certificate of Liability Insurance INSURER(S) AFFORDING COVERAGE NAIC # IN SLJRER INSURER INSLJRER INSURER ADDITIONAL POLICIES If a policy below does not include limit information, refer to the corresponding policy on the ACORD certificate form for policy limits. INSR LTR TYPE OF INSURANCE ADDL INSD St 13R NN.D POLICY NL'11BE12 POLICY EFFECTIVE DATE MM/DD POLICY EXPIRATION DATE MM/DD/YYYY LIMITS WORKERS COMPENSATION B N/A wc014267786 MA, OH, WA, WI 07/01/2015 07/01/2016 B N/A wc014267785 IL, KY, INC, UT 07/01/2015 07/01/2016 B N/A wc014267782 NJ, PA 07/01/2015 07/01/2016 B N/A wc014267784 AZ, GA, VA 07/01/2015 07/01/2016 B N/A wc014267781 FL 07/01/2015 07/01/2016 ACORD 101 (2008/01) © 2008 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD