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HomeMy WebLinkAbout114340 CUSTOM SERVICES OF COLORADO INC - INSURANCE CERTIFICATE (7)ACCWH CERTIFICATE OF LIABILITY INSURANCE Ill12/16/2015 DATE (MM/DDIYYYY) 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 Ewing -Leavitt Insurance Agency 4025 St. Cloud Dr. Suite 100 Loveland CO 80538 CONTACT Karole Peters NAME: AHCNNo E:: (970) 679-7355 FAX No: (866)237-2178 ADDRESS:karole-peters@leavitt.com INSURERS AFFORDING COVERAGE NAIC N INSURERA:Secura Insurance 22543 INSURED Custom Services of Colorado, Inc. PO Box 800 Mead CO 80542-0800 1 INSURERB:Pinnacol Assurance 41190 _INSURERC: INSURER D INSURER E : INSURER F: COVERAGES CERTIFICATE NUMBER:16-17 WC renewal 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 rypE OF INSURANCE ADDL SUBR POLICYNUMBER POLICY EFF MM/DDIYYYY POLICY EXP MMIDDIYYYY LIMITS A X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE � OCCUR Blkt Addl Insured I 20-TC-0003160361-5 Additional Insured for On -going Operations Only 1 3/29/2015 3/29/2016 1 EACH OCCURRENCE $ 1,000,000 DAMAGETTED PREMSESOEaoccu ence $ 100,000 X MED EXP (Any one person) $ 5,000 X Blkt Waiver of Sub PERSONAL &ADV INJURY $ Included GENT AGGREGATE LIMIT APPLIES PER: POLICY 1XI PRO- JECT LOC OTHER: GENERAL AGGREGATE $ 2,000,000 PRODUCTS - COMP/OP AGG $ 2,000,000 $ A AUTOMOBILE LIABILITY ANY AUTO ALL OWNED SCHEDULED AUTOS AUTOS X NON -OWNED HIRED AUTOS AUTOS 20-A-003160362-5 3/29/2015 3/29/2016 COMBINED SINGLE LIMIT Ea accident $ 1 000 000 X BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ X PROPERTY DAMAGE Per accident $ A X UMBRELLA LIAB EXCESS LIAB X OCCUR CLAIMS -MADE 20-CU-003160363-5 3/29/2015 3/29/2016 EACH OCCURRENCE $ 1,000,000 AGGREGATE $ 1,000,000 DED I X I RETENTION$ 10,000 $ 3/ B _ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY YIN ANY PROPRIETOR/PARTNER/EXECUTIVE ❑ MFFICERIMEn BER EXCLUDED? (Mandatory ) If yes, describe under DESCRIPTION OF OPERATIONS below N/A 4025555 Blanket Waiver of Subrogation Included 4 1/1/2016 1/1/2017 X PER OTH- STATUTE ER E.L. EACH ACCIDENT $ 1,000,000 E.L. DISEASE - EA EMPLOYEE $ 1,000,000 E.L. DISEASE - POLICY LIMIT $ 1,000,000 A Leased or Rented Equipment 20-TC-0003160361-5 3/29/2015 3/29/2016 Limit with$500 deductible $25,000 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) City of Ft. Collins is shown as additional insured as respects General Liability ILD14aIL211TL•ll7iLei W la: N_10 LH a M A_\ I Lei City of Ft. Collins 256 W. Mountain Avenue P. O. Box 580 Ft. Collins, CO 80522-0580 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 e Peters/KAPETE �� ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25 (2014/01) The ACORD name and logo are registered marks of ACORD INS025 (201401)