HomeMy WebLinkAboutFMLASOURCE INC - INSURANCE CERTIFICATE (4)ACORO®
CERTIFICATE OF LIABILITY INSURANCE
DATE (MMIDD/YYYY)
F12/23/2015
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
Van Wagner Agency
PO Box 9017
135 Crossways Park Drive
CONTACT
NAME:
PHONE 800 735 1588 FAX
888 290-0302
EMAIL , request@sterlingrisk.com
INSURERS AFFORDING COVERAGE
NAIC #
Woodbury NY 11797
INSURER A: Granite State Insurance Company
23809
_
INSURED
INSURER B :The Hartford
914
FMLASource, Inc.
455 N.Cityfront Plaza Dr,13thF
Chicago IL 60611-5503
INSURER C:
INSURER D
INSURER E :
INSURER F
rOVFRAr,FS CFRTIFICATF NIIMRFR• 1832420095 RFVIRION 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
7ypE OF INSURANCE INSD
WVD
POLICY NUMBER
POLICY EFF POLICY EXP
MM/DD/YVVY MM/DD/YYYY
LIMITS
A
X
COMMERCIAL GENERAL LIABILITY
02LX00899647711000
111/2016
1/1/2017
EACH OCCURRENCE
$1.000,000
CLAIMS -MADE �X OCCUR
DAMAGE TO RENTED
PREMISES Ea occurrence
$1,000,000
VIED EXP (Any one person)
$5,000
PERSONAL SADVINJURY
$1,000,000
GEN'L AGGREGATE LIMIT APPLIES PER:
GENERAL AGGREGATE
$3,000,000
POLICY] JET LOC
PRODUCTS - COMP/OPAGG
$1,000.000
$
OTHER:
A
AUTOMOBILE
LIABILITY
02CA0661436567000
1/1/2016
1/1/2017
Ea accident
$1,000,000
BODILY INJURY (Per person)
$
ANY AUTO
ALL8WNED SCHEDULED
AUTX AUTOS
BODILY INJURY (Per accident)
$
NON -OWNED
HIRED AUTOS X AUTOS
RDAMAGE$
Per accident)
A
X
UMBRELLA LAB X
OCCUR
29UD00406732716000
1/1/2016
111/2017
EACH OCCURRENCE
$15,000,000
AGGREGATE
$15,000,000
EXCESS LIAB !
CLAIMS -MADE
I
DIED X RETENTION$ 10,000
$
B
WORKERS COMPENSATION
AND EMPLOYERS' LIABILITY Y / N
NY PROPRIETOR/PARTNER/EXECUTIVE
12WEPK5818
1/1/2016
1/1/2017
PER TH-
PEA
STATUTE ER
E.L. EACH ACCIDENT
$1,000,000
OFFICER/MEMBER EXCLUDED?
NIA
E.L. DISEASE - EA EMPLOYEE
$1,000,000
(Mandatory in NH)
If yes, describe under
DESCRIPTION OF OPERATIONS below
E.L. DISEASE - POLICY LIMIT
$1.000,000
A
Professional
02LX00899647711000
1/1/2016
1/1/2017
Per Occurrence 1,000,000
Liability
Aggregate 3,000,000
DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required)
The City of Fort Collins, its officers, agents and employees are included as additional insureds as respects to General Liability when required
by WRITTEN CONTRACT prior to a loss.
CERTIFICATE HOLDER CANCELLATION 30 Days
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
City of Fort Collins
ACCORDANCE WITH THE POLICY PROVISIONS.
215 N. Mason Street
2nd Floor
AUTHORIZED REPRESENTATIVE
Fort Collins, CO 80522
@ 1988-2014 ACORD CORPORATION. All rights reserved.
ACORD 25 (2014/01) The ACORD name and logo are registered marks of ACORD