HomeMy WebLinkAboutTIMOTHY M KEOHANE - INSURANCE CERTIFICATE (4)Erie
a\ Insurance
100 Erie Ins. PI. • Erie, PA 16530
CERTIFICATE OF INSURANCE
- THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY -
CERTIFICATE HOLDER COPY
NAME AND NUMBER OF AGENCY
KELLY FAMILY INSURANCE AGY INC NN 1 037
196 S MAIN ST
NAPLES , NY 14512-9508 585-374-932
NAME AND ADDRESS OF NAMED INSURED
TIMOTHY M KEOHANE
PO BOX 662
NAPLES NY 14512-0662
DATEISSUED 01/18/2016
NAME AND ADDRESS OF CERTIFICATE HOLDER
CITY OF FORT COLLINS
117 N MASON ST
FORT COLLINGS CO 80524—
This is to certify that policies, as indicated by Policy Number below, are in force for the Named Insured at the time that the certificate is being issued. I
GENERAL LIABILITY Q267220068 02/22/2016 02/22/2017
COMMERCIAL GENERAL LIABILITY
OCCURRENCE FORM
GEN'LAGGREGATE LIMIT APPLIES
PER: POLICY
WORKERS COMPENSATION Q867200103 02/22/2016 02/22/2017
EACH OCCURRENCE $ 300000
FIRE DAMAGE
(Any one premises) $ 300000
MED EXP (Any one person) $ 5000
( PERSONAL & ADV INJURY I$ 300000 I:
GENERAL AGGREGATE I $ 600000 1
PRODUCTS-COMP/OP AGGI $ 600000
(EACH PERSON) $
BODILY INJURY $
EACH ACCIDEN
PROPERTY DAMAGE $
BODILY INJURY AND $
PROPERTY DAMAGE
COMBINED
EACH OCCURRENCE
AGGREGATE
STATUTORY
AND BODILY ACCIDENT $ EACH ACCIDENT
FiNPI_ nYFR$ I IGRII.ITY L�;,; —Y D!SE.4SE � 100000500000 POLICY LIMIT
BY DISEASE $ 100000 EACH EMPLOYEE
DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS
CANCELLATION: SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE
DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS.
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).
THIS CERTIFICATE IS ISSUED FOR INFORMATION PURPOSES ONLY AND
CONFERS NO RIGHTS ON THE CERTIFICATE HOLDER. IT DOES NOT
AFFIRMATIVELY OR NEGATIVELY LIST, AMEND, EXTEND OR OTHERWISE
ALTER THE TERMS, EXCLUSIONS AND CONDITIONS OF INSURANCE
COVERAGE CONTAINED IN THE POLICY(IES) INDICATED ABOVE. THE TERMS
AND CONDITIONS OF THE POLICY(IES) GOVERN THE INSURANCE COVERAGE
AS APPLIED TO ANY GIVEN SITUATION. LIMITS SHOWN MAY HAVE BEEN
REDUCED BY CLAIMS PAID. THIS CERTIFICATE OF INSURANCE DOES NOT
CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED
REPRESENTATIVE OR PRODUCER AND CERTIFICATE HOLDER.
ERIE INSURANCE
AUTHORIZED
REPRESENTATIVE
SEE REVERSE SIDE
OF-1568 09/12 CIF