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HomeMy WebLinkAboutJAX INC - INSURANCE CERTIFICATEACORO® CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DD/YYYY) 12/31/2015 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 Flood and Peterson Po Box 578 Greeley CO 80632 CONTACT NAME: Miller, CISR PHC NE (970)266-7148 A/C No: (970)506-6845 IL ADDRESS:M4iller@floodpeterson.com INSURERS AFFORDING COVERAGE NAIC N INSURER AContinental Western Group 10804 INSURED Jax, Inc. P.O. Box 469 Bellvue CO 80512 INSURER B :Pinnacol Assurance 41190 INSURERC:Zurich American Insurance Company INSURERD: INSURER E : 1INSURERF: COVERAGES CERTIFICATE NUMBER CL15123108154 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: UBR POLICY NUMBER POLICY EFF MM/DD/YYYY POLICY EXP MM/DD/YYYY LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 A CLAIMS -MADE OCCUR X DAMAGE TO RENTED PREMISES Ea occurrence $ 500,000 MED EXP (Any one person) $ 5,000 3115682 1/9/2016 1/9/2017 PERSONAL & ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 JE PO - POLICY LOC PRODUCTS - COMP/OP AGG $ 2,000,000 PERLO $ OTHER. AUTOMOBILE LIABILITY (CEO,MeccidentBINED SINGLE LIMIT $ 1,000,000 BODILY INJURY (Per person) $ A X ANY AUTO ALL AUTOS TOSCHEDULED AUTOS 3115682 1/9/2016 1/9/2017 BODILY INJURY (Per accident) $ PROPERTY DAMAGE Per accident $ NON -OWNED X HIRED AUTOS X AUTOS Uninsured motorist combined $ 1,000,000 X UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 5,000,000 AGGREGATE $ 5,000,000 A EXCESS LIAB CLAIMS -MADE DED RETENTION$ $ 3115682 1/9/2016 1/9/2017 WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y / N X PER OTH- STATUTE ER ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/B MandatoMEn NH BER EXCLUDED? (Mandatory � ) NIA 4161344 1/1/2016 1/1/2017 E.L. EACH ACCIDENT $ 500,000 E.L. DISEASE - EA EMPLOYE $ 500,000 If yes, describe under DESCRIPTION OF OPERATIONS below I I E.L. DISEASE - POLICY LIMIT 1 $ 500,000 C Workers' Compensation WC969190003 1/1/2016 1/1/2017 500,000/500,000/500.000 Other States Coverage DESCRIPTION OF OPERATIONS / LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) City of Fort Collins is included as Additional Insured as required by written contract with respects to General Liability arising out of work performed by the named insured. t.aK I Ir'IL A I t MULUtK 1L ANL tLLA I IUN City of Fort Collins P.O. Box 580 Fort Collins, CO 80522-0000 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 ACORD 25 (2014/01) INS025r?m4ml K Miller, CISR/KMILLE ©1988-2014 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD