HomeMy WebLinkAbout102829 DON KEHN CONSTRUCTION - INSURANCE CERTIFICATE (5)Client#: 34206 DONKEHPC
ACORD, CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY)
10/02/2015
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
NAME:
Holmes Murphy -Colorado PHONE 515 223-6800FAX
A/C, No EM : A/C No :
7600 East Orchard Rd, Ste 330 E-MAIL
South ADDRESS: _ _
INSURER(S) AFFORDING COVERAGE NAIC #
Greenwood Village, CO 80111 INSURER A: Pinnacol Assurance Company 141190
INSURED INSURER B :
Don Kehn Construction, Inc.
6550 S. County Road 5 INSURERC:
Fort Collins, CO 80528 INSURERD:
COVERAGES CERTIFICATE NUMBER: 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 CONTRACTOR 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.
IINSR
LTR
TYPE OF INSURANCE
ADDL
INSR
SUBR
WVD
POLICY NUMBER
POLICY EFF
MM/DD/YYYY
POLICY EXP
MM/DD/YY
LIMBS
GENERAL LIABILITY
COMMERCIAL GENERAL LIABILITY
CLAIMS -MADE 7 OCCUR
EACH OCCURRENCE
_
$
$.
PREMISES Ea occu ence
MED EXP (Any one person)
$
PERSONAL & ADV INJURY
$
$
GENERAL AGGREGATE
GEN'L AGGREGATE LIMIT APPLIES PER:
POLICY PRO-JECT 17 LOC
PRODUCTS - COMP/OP AGG
$
$
AUTOMOBILE
LIABILrY
ANY AUTO
ALL OWNED SCHEDULED
AUTOS AUTOS
HIRED AUTOS NON -OWNED
AUTOS
COMBINED SINGLE LIMIT
Ea accident
BODILY INJURY (Per person)
$
BODILY INJURY (Per accident)
$
PROPERTY DAMAGE
Per accident
$
UMBRELLA LIAB
EXCESS LIAB
OCCUR
CLAIMS -MADE
EACH OCCURRENCE
$
AGGREGATE
$
DED RETENTION $
$
A
WORKERS COMPENSATION
AND EMPLOYERS' LIABILITY
ANY PROPRIETOR/PARTNER/EXECUTIVE Y / N
OFFICER/MEMBER EXCLUDED? �
(Mandatory in NH)
If yes, describe under
DESCRIPTION OF OPERATIONS below
N/A
2093950
10/01 /2015
10/01 /201
X TO Y LIMIT OTH-
E.L. EACH ACCIDENT
$500,000
E.L. DISEASE - EA EMPLOYEE
s500OOO
E.L. DISEASE - POLICY LIMIT
$500000
DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required)
Project Description: 6045 Asphalt Supply
t,rri I Iril.A i C r1ULUr-rl L.HIVI.t LLH I IUIN
City of Fort Collins SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
Administrative Services ACCORDANCE WITH THE POLICY PROVISIONS.
Purchasing Division;PO Box 580
Fort Collins, CO 80522-0580 AUTHORIZED REPRESENTATIVE
01988-2010 ACORD CORPORATION. All rights reserved.
ACORD 25 (2010/05) 1 of 1 The ACORD name and logo are registered marks of ACORD
#S161642/M161619 LINR1