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HomeMy WebLinkAboutGARNEY HOLDING COMPANY - INSURANCE CERTIFICATE (7)DATE (MM/DDIYYYY) ACORO� CERTIFICATE OF LIABILITY INSURANCE `,,,,� Fg/28/2015 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 endorsements . PRODUCER CONTACT NAME: Aubrey Meyer Arthur J. Gallagher Risk Management Services, Inc. PHONE (816) 395 8593 °AX (816) 467 5593 2345 Grand Blvd., Suite 400 E-MAIL Kansas City MO 64108 ESS: aubrey_meyer@ajg.com INSURED GARNCOM-01 Garney Holding Company (See attached list of Additional Named Insureds) 1333 NW Vivion Road Kansas City MO 64118 INSURER A: Travelers ERC: ER E : Casualty Co of A r(1VFRAnrFl r.FRTIFIrATF NIIMRFR- 52598912 I?F\/ICICIN NIIMRFR• 5674 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 INSD WV POLICY NUMBER POLICY EFF MMIDD/YYYY POLICY EX MIDD/YYYY -— LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ GE TO HFN ILU CLAIMS -MADE OCCUR PREEMISES (Ea occurrence) $ MED EXP (Any one person) $ PERSONAL & ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ POLICY L� PRO LOC JECT PRODUCTS - COMP/OP AGG $ f OTHER: AUTOMOBILE LIABILITY Ea accident $ BODILY INJURY (Per person) S ANLY AUTO AUTOSNED SCHEDULED BODILY INJURY (Per accident) f NON -OWNED HIRED AUTOS AUTOS APer accident G E $ A X UMBRELLA LIAB X OCCUR Y Y ZUP-14S78452-15-NF 0/1/2015 10/1/2016 EACH OCCURRENCE $15,000,000 AGGREGATE $ EXCESS LIAB CLAIMS -MADE DED IX I RETENTION$None $ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY YIN OTH- STATUTE ER ANY PROPRIETOR/PARTNER/EXECUTIVE E.L. EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? ❑ NIA — E.L. DISEASE - EA EMPLOYEE $ (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT $ DESCRIPTION OF OPERATIONS I LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached it more space is required) Following Form Primary/Underlying Policies with Liberty Mutual Fire Insurance Company: General Liability including Completed Operations Policy #TB2-641-426942-725, Eff. 10-1-2015/10-1-2016 Automobile Liability Policy #AS2-641-426942-715, Eff. 10-1-2015/10-1-2016 Employers Liability/Workers' Compensation Policy #WA2-64D-426942-735, Eff. 10-1-2015/10-1-2016 Following Form Including Blanket Additional Insured, Primary and Non -Contributory and Blanket Waiver of Subrogation as required by written contract. Includes All Work and Operations Performed by insured covered by Primary/Underlying policies. See Attached... ULK I II- ILA I t HULUtK UA1VL tLLA I IUIV City of Fort Collins P.O. Box 580 215 North Mason Street, 2nd Flolor Fort Collins CO 80522 USA SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. DRIZED REPRESENTATIVE © 1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25 (2014/01) The ACORD name and logo are registered marks of ACORD AGENCY CUSTOMER ID: GARNCOM-01 _ LOC #: AC" ADDITIONAL REMARKS SCHEDULE Pagel of 1 AGENCY Arthur J. Gallagher Risk Management Services, Inc. NAMED INSURED Garney Holding Company (See attached list of Additional Named Insureds) 1333 NW Vivion Road POLICY NUMBER Kansas City MO 64118 CARRIER NAIC CODE EFFECTIVE DATE: ADDITIONAL REMARKS THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, FORM NUMBER: 25 FORM TITLE: CERTIFICATE OF LIABILITY INSURANCE Named Insureds include: Garvey Holding Company Garvey Companies, Inc. Garney Construction Company, Inc. Grimm Construction Company, Inc. Garvey Wyoming, Inc. Garvey New Mexico, Inc. Garney Federal, Inc. Encore Construction Group, Inc. Garvey Colorado, LLC Garvey Water Partnership Garvey Pacific, Inc. Following Form Primary/Underlying Policies with Liberty Mutual Fire Insurance Company: General Liability including Completed Operations Policy #TB2-641-426942-724 Eff. 10 2014/10-1-2015 Auto Liability Policy #AS2-641-426942-714 Eff. 10-1-2014110-1-2015 Employers Liability/Workers' Compensation Policy #WA2-64D-426942-734 Eff. 10-1-2014/10-1-2015 Following Form Including Blanket Additional Insured, Primary and Non -Contributory and Blanket Waiver of Subrogation as required by written contract. Includes All Work and Operations Performed by insured covered by Primary/Underlying ACORD 101 (2008/01) © 2008 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD ACOR" CERTIFICATE OF LIABILITY INSURANCE DATE (MMIDD/YYYY) 1 9/28/2015 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 endorsements . PRODUCER CONTACT NAME: AubreyMe er Arthur J. Gallagher Risk Management Services, Inc. PHONE 2345 Grand Blvd., Suite 400 o, Ea): (816) 395 8593 F (816) 467 5593 Kansas City MO 64108 E-MAIL . aubrey_meyer@ajg.com INSURED GARNCOM-01 Garney Holding Company (See attached list of Additional Named Insureds) 1333 NW Vivion Road Kansas City MO 64118 A:Travelers Property Casualty Co of A 125674 INSURER C : INSURER D : INSURER E : rf1VFRAr:FS r`FRTIFICATF NIIMRFR• 711745408 RFVI-q[ON NI]MRFR- 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 AUDLISUBIR IN D WVD POLICY NUMBER POLICY EFF WDDIYYYY POLICY EXP MM/DD/YY LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $RENTEU- - CLAIMS -MADE 17 OCCUR PREMWSE�aoccurrence $ MED EXP (Any one person) $ PERSONAL & ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ POLICY PRO- ❑ JECT LOC PRODUCTS -COMP/OP AGG $ $ OTHER: AUTOMOBILE LIABILITY Ea accident $ BODILY INJURY (Per person) $ ANY AUTO AUTOS NED SCHEDULED UTOS BODILY INJURY (Per accident) $ NON -OWNED HIRED AUTOS AUTOS PROPER AMAGE--- Per accident $ E A X UMBRELLA LIAB X OCCUR Y Y ZUP-14S78452-15-NF 10/1/2015 10/1/2016 EACH OCCURRENCE $15,000,000 AGGREGATE $15,000,000 EXCESS LIAB CLAIMS -MADE DED I X I RETENTION s None $ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y /N STATUTE ER _. ANY PROPRIETOR/PARTNER/EXECUTIVE E.L. EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? ❑ NIA --- (Mandatory in NH) E.L. DISEASE - EA EMPLOYE $ It yes, describe under DESCRIPTION OF OPERATIONS below - $ E.L. DISEASE - POLICY LIMIT DESCRIPTION OF OPERATIONS / LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached If more space Is required) Following Form Primary/Underlying Policies with Liberty Mutual Fire Insurance Company: General Liability including Completed Operations Policy #TB2-641-426942-725, Eff. 10-1-2015/10-1-2016 Automobile Liability Policy #AS2-641-426942-715, Eff. 10-1-2015/10-1-2016 Employers Liability/Workers' Compensation Policy #WA2-64D-426942-735, Eff. 10-1-2015/10-1-2016 Following Form Including Blanket Additional Insured, Primary and Non -Contributory and Blanket Waiver of Subrogation as required by written contract. Includes All Work and Operations Performed by insured covered by Primary/Underlying policies. See Attached... GLK I II-IL;A I L HL)LL)LK L;ANL;LLLA I IUN City of Fort Collins P.O. Box 580 215 North Mason Street, 2nd Flolor 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. PRIZED REPRESENTATIVE © 1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25 (2014/01) The ACORD name and logo are registered marks of ACORD AGENCY CUSTOMER ID: GARNCOM-01 LOC *: 4C" AnnITIMMA1 RFMARK-q S(:HFni n F AGENCY Arthur J. Gallagher Risk Management Services, Inc. POLICY NUMBER CARRIER NAIC CODE NAMED INSURED Garney Holding Company (See attached list of Additional Named Insureds) 1333 NW Vivion Road Kansas City MO 64118 EFFECTIVE DATE: AUUI I IUIVAL KtMAKr%3 FIS DDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, NUMBER: 25 FORMTITLE: CERTIFICATE OF LIABILITY INSURANCE Named Insureds include: Garney Holding Company Garney Companies, Inc. Garney Construction Company, Inc. Grimm Construction Company, Inc. Garney Wyoming, Inc. Garney New Mexico, Inc. Garney Federal, Inc. Encore Construction Group, Inc. Garney Colorado, LLC Garney Water Partnership Garney Pacific, Inc. Paqe 1 of i ACORD 101 (2008/01) Q 2008 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD A�� ® DATE (MMIDDNYYY) �, CERTIFICATE OF LIABILITY INSURANCE F9/28/201 5 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 policy0es) 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 endorsements . PRODUCER CON AC NAME. Aubrey Meyer Arthur J. Gallagher Risk Management Services, Inc. PHONE 816 395 8593 FAX (816) 467 5593 2345 Grand Blvd., Suite 400 (AI "° E't')- ( )VC. Kansas City MO 64108 ADDRESS: aubrey_meyer@ajg.com INSURER(S) AFFORDING COVERAGE NAIC M Travelers Prooertv Casualtv Co of A 25674 INSURED GARNCOM-01 INSURER B : INSURERC: Garney Holding Company INSURERD: (See attached list of Additional Named Insureds) 1333 NW Vivion Road Kansas City MO 64118 INSURERE: rnXIFDA(2117C CFDTIPIr`ATF NI IRARFD- 1042218752 BFVISIr1N NIIMRFR- 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 INSD WVD POLICY NUMBER POLICY EFF MMIDDIYYYY POLICY EXP WDDIYY LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE E CLAIMS -MADE 7 OCCUR E6 PREMISES Ea occurrence E MED EXP (Any one person) E _ PERSONAL & ADV INJURY E GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE E POLICY PRO LOC JECT PRODUCTS - COMP/OP AGG S $ OTHER: AUTOMOBILE LIABILITY Ea accident)E BODILY INJURY (Per person) E ANY AUTO AUTOS OWNED SCHEDULED BODILY INJURY (Per accident) $ NON -OWNED HIRED AUTOS AUTOS OPERTYD Per accident $ E A X UMBRELLALIAB X OCCUR Y Y ZUP-14S78452-15-NF 10/1/2015 10/1/2016 EACH OCCURRENCE $15,000,000 AGGREGATE E EXCESS LIAB CLAIMS_ -MADE DED X I RETENTION E None E WORKERS COMPENSATION AND EMPLOYERS' LIABILITY YIN ANY PROPRIETOR/PARTNER/EXECUTIVE STATUTE FOR E.L. EACH ACCIDENT $ OFFICERWEMBER EXCLUDED? NIA -- (Mandatory in NH) I E.L. DISEASE - EA EMPLOYE E It as, describe under DESCRIPTION OF OPERATIONS below 1 $ E.L. DISEASE - POLICY LIMIT DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached If more space is required) Following Form Primary/Underlying Policies with Liberty Mutual Fire Insurance Company: General Liability including Completed Operations Policy #TB2-641-426942-725, Eff. 10-1-2015/10-1-2016 Automobile Liability Policy #AS2-641-426942-715, Eff. 10-1-2015/10-1-2016 Employers Liability/Workers' Compensation Policy #WA2-64D-426942-735, Eff. 10-1-2015/10-1-2016 Following Form Including Blanket Additional Insured, Primary and Non -Contributory and Blanket Waiver of Subrogation as required by written contract. Includes All Work and Operations Performed by insured covered by Primary/Underlying policies. See Attached... CERTIFICATE HOLDER CANCELLATION City of Fort Collins P.O. Box 580 215 North Mason Street, 2nd Flolor Fort Collins CO 80522 USA 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 1 O 1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25 (2014/01) The ACORD name and logo are registered marks of ACORD 4C"R AGENCY CUSTOMER ID: GARNCOM-01 LOC #: AnnITInKlAll DPRAADV4Z CPUC7n111 C7 AGENCY NAMED INSURED Arthur J. Gallagher Risk Management Services, Inc. Garney Holding Company POLICY NUMBER (See attached list of Additional Named Insureds) 1333 NW Vivion Road Kansas City MO 64118 CARRIER NAIC CODE EFFECTIVE DATE: AUUI I IONAL REMARKS F DDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, NUMBER: 25 _ FORM TITLE: CERTIFICATE OF LIABILITY INSURANCE Named Insureds include: Garney Holding Company Garvey Companies, Inc. Garney Construction Company, Inc. Grimm Construction Company, Inc. Garney Wyoming, Inc. Garney New Mexico, Inc. Garney Federal, Inc. Encore Construction Group, Inc. Garney Colorado, LLC Garney Water Partnership Garney Pacific, Inc. Following Form Primary/Underlying Policies with Liberty Mutual Fire Insurance Companyy: General Liability including Completed Operations Policy #TB2-641-426942-724 Eff. 10-1-2014/10-1-2015 Auto Liability Policy #AS2-641-426942-714 Eff. 10-1-2014/10-1-2015 Employers Liability/Workers' Compensation Policy #WA2-64D-426942-734 Eff. 10-1-2014/10-1-2015 Following Form Including Blanket Additional Insured, Primary and Non -Contributory and Blanket Waiver of Subrogation as required by written contract. Includes All Work and Operations Performed by insured covered by Primary/Underlying D.- . -r AGURD 101 (2008/01) © 2008 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD ACOR" CERTIFICATE OF LIABILITY INSURANCE -DATE `111 1 9/28/2015 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 endorsements . PRODUCER CONTACTNAME: Aubrey Meyer Arthur J. Gallagher Risk Management Services, Inc. PHONE FAX 2345 Grand Blvd., Suite 400 C W_EXlJ (816) 395-8593 (816) 467 5593 Kansas City MO 64108 E- LE . aubrey_meyer@ajg.com INSURER(S) AFFORDING COVERAGE NAIC # INSURER A: Travelers Property Casualty Co of A 25674 INSURED GARNCOM-01 INSURER B: INSURERC; Garney Holding Company INSURERD: (See attached 1st of Additional Named Insureds) 1333 NW Vivion Road Kansas City MO 64118 INSURERE: rr)%11FRAn1FS rFRTIFIr_ATF NIIMRFR• 1098123007 RFVISIt7111 NIIMRFR- 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 AUUL�bUBKI INSD WVD i POLICY NUMBER POLICY EFF MMIDDNYYY POLICY EXP MMIDDIYYYY LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ ­DAWGr1_ORENTED CLAIMS -MADE OCCUR PREMISES Ea occurrence $ MED EXP (Any one person) $ PERSONAL & ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ POLICY PRO ❑ JECT LOC PRODUCTS - COMP/OP AGG $ $ OTHER: AUTOMOBILE LIABILITY Ea accident SINGLE LIMIT $ BODILY INJURY (Per person) $ ANY AUTO AUTOS NED SCHEDULED BODILY INJURY (Per accident) $ HIRED AUTOS NON -OWNED AUTOS Per accident $ E A X UMBRELLA LIAB X OCCUR Y Y ZUP-14S78452-15-NF 10/1/2015 10/1/2016 EACH OCCURRENCE $15,000,000 AGGREGATE $15,000,000 EXCESS LIAB CLAIMS -MADE DED IX I RETENTION $ None $ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y / N OTH- STATUTE ER ANY PROPRIETOR/PARTNER/EXECUTIVE E.L. EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? ❑ NIA ' (Mandatory in NH) E.L. DISEASE - EA EMPLOYE $ If yes, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT $ DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) Following Form Primary/Underlying Policies with Liberty Mutual Fire Insurance Company: General Liability including Completed Operations Policy #TB2-641-426942-725, Eff. 10-1-2015/10-1-2016 Automobile Liability Policy #AS2-641-426942-715, Eff. 10-1-2015/10-1-2016 Employers Liability/Workers' Compensation Policy #WA2-64D-426942-735, Eff. 10-1-2015/10-1-2016 Following Form Including Blanket Additional Insured, Primary and Non -Contributory and Blanket Waiver of Subrogation as required by written contract. Includes All Work and Operations Performed by insured covered by Primary/Underlying policies. See Attached... CERTIFICATE HOLDER CANCELLATION City of Fort Collins P.O. Box 580 215 North Mason Street, 2nd Flolor 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. PRIZED REPRESENTATIVE I/+ © 1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25 (2014/01) The ACORD name and logo are registered marks of ACORD AC"RO"1 AGENCY CUSTOMER ID: GARNCOM-01 LOC #: Af' nffinNAI RFMARKS S(.HM111 F AGENCY Arthur J. Gallagher Risk Management Services, Inc. POLICY NUMBER CARRIER I NAIC CODE DDITIONAI RFMARKS NAMED INSURED Garney HoldinCompany (See attached 1st of Additional Named Insureds) 1333 NW Vivion Road Kansas City MO 64118 EFFECTIVE DATE: THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, FORM NUMBER: 25 FORM TITLE: CERTIFICATE OF LIABILITY INSURANCE Named Insureds include: Garney Holding Company Garney Companies, Inc. Garney Construction Company, Inc. Grimm Construction Company, Inc. Garney Wyoming, Inc. Garney New Mexico, Inc. Garney Federal, Inc. Encore Construction Group, Inc. Garney Colorado, LLC Garney Water Partnership Garney Pacific, Inc. Paqe 1 of 1 ACORD 101 (2008/01) © 2008 ACORD CORPORATION. All rights reserved The ACORD name and logo are registered marks of ACORD