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HomeMy WebLinkAboutBIG HORN ROOFING INC - INSURANCE CERTIFICATE (4)A� �'© CERTIFICATE OF LIABILITY INSURANCE DATE (MMiDDIYYYY 7/13/2015 ' 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 CONTACT P AME: David Bell/Ste hanie Crozier N PHONE . (307) 367-3487 A/CfFAXNo (402)918-7546 BW Insurance Agency, Inc. 1100 Wilson, Suite #2 E-MAIL ADDRESS: Stephanie. crozier@bankofthewest.com PO BOX 2321 INSURERS AFFORDING COVERAGE NAIC # INSURER A :Continental Insurance Co Pinedale WY 82941 INSURED INSURERB:Valley Forge Insurance Company INSURERC:Continental Casualty Big Horn Roofing, Inc. INSURERD: 605 S Adams Street INSURER E : INSURERF: Laramie WY 82070 COVERAGES CERTIFICATE NUMBER:CL148675765 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 SUER POLICY NUMBER MM/DDPOLICYYYYY MM/DD/YYYY LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 X COMMERCIAL GENERAL LIABILITY DAMAGE RENTED PREMISES Ea occu ence) $ 100,000 B CLAIMS -MADE 7XOCCUR X Y 4029260862 9/l/2014 9/1/2015 VIED EXP (Any one person) $ 5,000 PERSONAL & ADV INJURY $ 1,000,000 GENERAL AGGREGATE S 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP/OP AGG $ 2 , 000 , 000 POLICY-]X PRO LOC $ AUTOMOBILE LIABILITY Ee aBINEDt SINGLE LIMIT $ 1,000,000 BODILY INJURY (Per person) S A ANY AUTO Ix BODILY INJURY (Peraccidenq $ ALL OWNED SCHEDULEDX Y4029260828 9/1/2014 9/1/2015 NON-OWNEDAUTOSAUTOS X PROPERTY DAMAGEHIRED $ AUTOS AUTOS Per accident Underinsured motorist S 1,000 000 X UMBRELLA LIAB X OCCUR EACH OCCURRENCE S 5,000,000 AGGREGATE $ 5,000,000 C EXCESS LIAB CLAIMS -MADE DED I X RETENTIONS io,00c $ X Y 4029286457 9/1/2014 9/1/2015 A WORKERS COMPENSATION Y X TWO STATU- X OTH- I ER AND EMPLOYERS' LIABILITY Y / NEmployers E.L. EACH ACCIDENT S 1,000,000 ANY PROPRIETOR/PARTNER/EXECUTIVE Liability ONLY OFFICER/MEMBER EXCLUDED? ❑ (Mandatory in NH) N / A 4029260862 9/1/2014 9/1/2015 E.L. DISEASE -EA EMPLOYE S 1, 000 , 000 If yes, describe under E.L. DISEASE - POLICY LIMIT S 1 000 000 DESCRIPTION. OF OPERATIONS below DESCRIPTION OF OPERATIONS / LOCATIONS I VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required) Contractor CERTIFICATE HOLDER CANCELLATION City of Fort Collins PO Box 580 Fort Collins, CO 80522 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 REPRESENTATIVE id Bell/SCPIN AGORO 25 (2010/05) INS025 (gmnns� m © 1988-2010 ACORD CORPORATION. All rights reserved. Tha Ar-r)Pr) n— nnrf Innn mra ronictorarl m—kc of Arr)Rr) J° State of Wyoming Department of Workforce Services `6 THE DIVISION OF WORKERS' COMPENSATION Delbert A. McOmie Matthew H. Mead 1510 East Pershing Boulevard Interim Director Governor Cheyenne, WY 82002 Lisa M. Osvold Deputy Director WORKERS' COMPENSATION CERTIFICATE OF GOOD STANDING City of Fort Collins P. O. Box 580 Fort Collins, CO 80522 Mail Date: July 14, 2015 Employer BIG HORN ROOFING INC 605 SOUTH ADAMS ST LARAMIE, WY 82070-6610 Expiration Date: July 13, 2016 This is to certify that the above employer has made contributions pursuant to Wyoming Workers' Compensation Act on its employees. The account is in good standing as of the above date. Wyoming Workers' Compensation Monthly/Quarterly Payroll Reports shall be filed and payments made on or before the last day of the month following the monthly/quarterly payroll periods. Prime contractors may verify good standing of a sub -contractor's business by contacting the division by telephone, after the initial certificate has been issued. In private work a contractor is liable for the payment of Workers' Compensation premiums for the employees of any sub- contractor if the sub -contractor primarily liable has not paid the premiums as provided in the act, pursuant to W.S. 27-14-206. Contractors should request a Certificate of Good Standing for a sub -contractor before making final settlement of the contract. Job Reference: License Renewal If you have any further questions regarding these changes, please call 307-777-6763 or fax 307-777-5298. Employer Services cc: Employer File CERTS We Bridge Human and Economic EMPLOYER SERVICES WC2543 Development for Wyoming's Future. PHONE: 307-777-6763 Revised 12/11 FAX: 307-777-5298 Page 1 of 2 www.wyomingworkforce.org