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HomeMy WebLinkAboutNORTH FORK NATIVE PLANTS - INSURANCE CERTIFICATEACOR©® �- CERTIFICATE OF LIABILITY INSURANCE DATE (MMIDD/YYYY) /1 /2016 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 Western Community Ins Co PO Box 4848 CONTACT NAME: ANDERSON MATT DEK PHONEFAX A/CExt: 208- 4-2 A/c No: 208-232-3608 EAIL A-0A DDRERE SS: commcerts@idfbins.com A IN AFFORDING COVERAGE NAIC # Pocatello, ID 83205-4848 INSURER A: Western Community Ins Co 39519 _ INSURED I'I IIn1��tI�II�rt Itlnitll ullltllltl lllllllln��t� NORTH FORK NATIVE PLANTS INC INSURER B : INSURER C: % JEFF KLAUSMANN & TIM WATERS INSURERD: INSURERE: PO BOX 1115 DRIGGS ID 83422 INSURERF: CnVFRAGFS CERTIFICATE NUMBER: REVISION NUMBER: AI-0418 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 OF INSURANCE ADDLTYPE 265& W POLICY NUMBER MM DDY EFF POLICY EXP MM` DDfYYYY LIMITS A GENERAL LIABILITY COMMERCIAL GENERAL LIABILITY CLAIMS -MADE Ill OCCUR Y N i 86892904 4/ 10/ 16 4/ 1 O/ 17 EACH OCCURRENCE $ 1.000.000 DAMAGE To RENTED PREMISES Ea occurrence $ 100.00 MED EXP (Any one person) $ PERSONAL a ADV INJURY $ GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: POLICY PRO- LOC PRODUCTS - COMP/OP AGG $ 2.000,000 $ A AUTOMOBILE LIABILITY ANY AUTO ALL OWNED SCHEDULED AUTOS AUTOS NON -OWNED X HIRED AUTOS X AUTOS Y N 86892904 4/10/16 4/10/17 COMBINED SINGLE LIMIT Ea accident BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ PROPERTY DAMAGE Per accident $ $ UMBRELLA LIAB EXCESS LIAB OCCUR CLAIMS -MADE EACH OCCURRENCE $ AGGREGATE $ DED I I RETENTION $ $ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y / N ANY PROPRIETOR/PARTNER/EXECUTIVE ❑ OFFICER/MEMBER EXCLUDED? (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below N / A WC STATIT OTH- R MIT ER E.L. EACH ACCIDENT $ E.L DISEASE- EA EMPLOYEE $ $ E.L. DISEASE - POLICY LIMIT DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Attach ACORD 101, Addltlonal Remarks Schedule, if more space Is required) ��u�I��ntllt�nl�I�t�n�t�11�I�n���nnt�I�n1��� CITY OF FORT COLLINS 215 N MASON ST FL 2 FORT COLLINS CO 80524 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 (2010/05) © 1988-2010 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD 4C0 AGENCY CUSTOMER ID: LOC #: AnniTInNAI RFMARKS SCHEDULE Page of AGENCY NAMED INSURED Western Community Ins Co NORTH FORK NATIVE PLANTS INC POLICY NUMBER % JEFF KLAUSMANN & TIM WATERS 86892904 PO BOX 1115 CARRIER NAICCODE DR I GGS I D 8 422 EFFECTIVE DATE: ,DDITIONAL REMARKS THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, FORM NUMBER: FORM TITLE: CITY OF FORT COLLINS is listed as an additional insured per endorsements CG 20 15 0 1 /88) I DCA 389(01 /04) ACORD 101 (2008/01) © 2008 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD