HomeMy WebLinkAboutJIM BLACK CONSTRUCTION INC - INSURANCE CERTIFICATE (3)® CERTIFICATE OF LIABILITY INSURANCE OATE(MM/DDIYYYY)
ACORO
��- 6/25/2015
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 NAME: Tan'sha_ Darden
Network Insurance Services,LLC PH0C.N Ex :30 -7 -9886 ac No: - 2
5261 S. Quebec St. Suite 100 E-MAIL
Greenwood Village CO 80111 ADDREss: anish networkin net
INSURER(SI AFFORDING COVERAGE NAIC p
INSURED JIMBL31
Jim Black Construction, Inc.
12279 Pennsylvania St
Thornton CO 80214
B:
-INSURER
INSURERC:
INSURERD:
COVERAGES CERTIFICATE NUMBER: 171.1;91C,'197 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 ADDL SUBR POLICY EFF POLICY EXP
LTR TYPE OF INSURANCE INSR WVD POLICY NUMBER MM/DDfYYYY MM/DD/YYYY LIMITS
GENERAL LIABILITY
EACH OCCURRENCE
$
COMMERCIAL GENERAL LIABILITY
_
$ _
DAMAGE TO RENTED
PREMISES Ea occurrence
MED EXP (Any one person)
CLAIMS -MADE - I OCCUR
$
PERSONAL & ADV INJURY
$
GENERAL AGGREGATE
$ _
GEN'L AGGREGATE LIMIT APPLIES PER:
PRODUCTS - COMP/OP AGG
$
$
POLICY I PRO LOC
AUTOMOBILE LIABILITY
COMBINED SM71l7TTqrI_
Ea accident
BODILY INJURY (Per person)
$
ANY AUTO
ALL OWNED SCHEDULED
AUTOS AUTOS
BODILY INJURY (Per accident)
$
PROPERTY DAMAGE
Per accident
$
1 NON OWNED
HIRED AUTOS AUTOS
UMBRELLA LIAB
OCCUR
EACH OCCURRENCE
$
AGGREGATE
$
EXCESS LIAB
CLAIMS -MADE
DED RETENTION $
$
A WORKERS COMPENSATION
AND EMPLOYERS' LIABILITY
I ANY PROPRIETOR/PARTNER/EXECUTIVE a
1 OFFICER/MEMBER EXCLUDED?
NIA
4132000
7/1/2015
7/1/2016
X WC STU- OTH-
T RYAT
ER
E.L. EACH ACCIDENT
$1,000,000
(Mandatory in NH)
E.L. DISEASE - EA EMPLOYEE
$1.000.000
E.L. DISEASE - POLICY LIMIT
If yes, describe under
DESCRIPTION OF OPERATIONS below
$1,000,000
B Contractor's Pollution Liability
Y
14CPLCWE00027
10/1/2014
10/1/2015
Each Occ Claim
�$4,000,000
$4,000,000 Aggregate
$10,000 Deductible
DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required)
re: All Projects
City of Fort Collins
PO Box 580
Fort Collins CO 80522
l.H1Y l..CLLH 1 IV IY
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
AUTHORIZED R, ESSEENT�ATIVEE
U 1988-2010 AGUKU GUKNUKAI IUN. All rlgnts reservea.
ACORD 25 (2010/05) The ACORD name and logo are registered marks of ACORD