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HomeMy WebLinkAboutROLEXIS INC DBA TEAM SPORT PHOTO - INSURANCE CERTIFICATE (5)A41CG7Rtf CERTIFICATE OF LIABILITY INSURANCE DATE2015 nYYY) 11 /17/01 s 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 CONTACT NAME: Sentry Customer Service WILLIAM J ALBERT PHONE FAX A/C t; 800-295-6919 A/C No: 800-514-7191 EMAIL ADDRESS: business roducts directOsent .com INSURER(S) AFFORDING COVERAGE NAIC # INSURER A: SENTRY INSURANCE A MUTUAL COMPANY 24988 INSURED INSURER B : ROLEXIS INC DBA TEAM SPORT PHOTO 11880 UPHAM STUNT A INSURER C INSURER D : BROOMFIELD, CO 80020 INSURER E : INSURER F : COVERAGES CERTIFICATE NUMBER: 0010 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 BF 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 INSR SUBR WVD POLICY NUMBER POLICY EFF MM/DD/YYY POLICY EXP MM/DD/YYY LIMITS A X BUSINESSOWNERS LIABILITY CLAIMS -MADE M OCCUR NON -OWNED AUTO X 49-99863-01 01/01/2016 01/01/2017 EACH OCCURRENCE $ 1,000,000 DAMAGE TO RENTED PREMISES PREMISES Ea occurrence 300,000 X MED EXP (Any one person) $ 10,000 X HIRED AUTO PERSONAL 3 ADV INJURY S GEN'L AGGREGATE LIMIT APPLIES PER: POLICY PRO- JECT LOC OTHER: GENERAL AGGREGATE $ 3,000,000 X PRODUCTS - COMP/OP AGG $ 3,000,000 $ AUTOMOBILE LIABILITY ANY AUTO ALL OWNED SCHEDULED AUTOS AUTOS HIRED AUTOS NON -OWNED AUTOS COMBINED SINGLE LIMrr $ BODILY INJURY (Per person) S BODILY INJURY (Per accident) S PROPERTY DAMAGE Per accident $ $ UMBRELLA LIAR EXCESS LIAB OCCUR CLAIMS -MADE EACH OCCURRENCE $ AGGREGATE S DED , RETENTION $ g 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 STATUTE �R7}{ E.L. EACH ACCIDENT S E.L. DISEASE - EA EMPLOYEE S E.L. DISEASE - POLICY LIMIT $ DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, maybe attached if more space is required) CERTIFICATE HOLDER CANCELLATION CITY OF FORT COLLINS SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE 215 N MASON ST2ND FL THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN PO BOX 580 ACCORDANCE WITH THE POLICY PROVISIONS. FORT COLLINS, CO 80524 AUTHORIZED REPRESENTATIVE ACORD 25 (2014/01) Page 1 of 2 © 1988-2014 ACORD CORPORATION. All rights reserved. 4999863 0010 The ACORD name and logo are registered marks of ACORD 11 /17/2015 1 00001 0000000213 15322 0 N AE21E852-BE69-405B-AD38-D014A9E9064F AGENCY CUSTOMER ID: ACORO® AGENCY WILLIAM J ALBERT POLICY NUMBER 49-99863-01 CARRIER ADDITIONAL REMARKS LOC #: — ADDITIONAL REMARKS SCHEDULE NAIC CODE NAMED INSURED ROLEXIS INC DBA TEAM SPORT PHOTO EFFECTIVE DATE: 01/01/2016 Page 2 of 2 ACORD 101 (2008/01) © 2008 ACORD CORPORATION. All rights reserved. 4999863 The ACORD name and logo are registered marks of ACORD 11/17/2015 SENTRY INSURANCE A MUTUAL COMPANY SENTRY'S BUSINESSOWNERS STEVENS POINT, WISCONSIN POLICY (A PARTICIPATING MUTUAL COMPANY) A MEMBER OF THE SENTRY FAMILY OF INSURANCE COMPANIES POLICY NUMBER 49-99863-01 NAME INSURED: ROLEXIS INC DBA TEAM SPORT PHOTO ADDITIONAL INSURED SCHEDULE The following information is required to complete the accompanying additional insured endorsement which forms a part of the Named Insured's BUSINESSOWNERS POLICY. ADDITIONAL INSURED ENDORSEMENT CITY OF FORT COLLINS BP 04 50 07 13 215 N MASON ST 2ND FL PO BOX 580 FORT COLLINS, CO 80524 (CERTIFICATE NUMBER 0010) LOCATION(S) OF COVERED OPERATIONS CITY OF FORT COLLINS PO BOX 580 215 N MASON ST 2ND FL FORT COLLINS, CO 80522 JOB: GOING ONSITE TO TAKE PHOTOS FOR ENDORSEMENT TEXT, SEE OVER. BP 89 05 01 87 (MECH) TEA 49-99863-01 00 161 11-17-2015 (000 0010) EFFECTIVE FROM JANUARY 01, 2016 TO JANUARY 01, 2017 oineORG 01315 POLICY NUMBER: BUSINESSOWNERS BP 04 50 07 13 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - OWNERS, LESSEES OR CONTRACTORS - SCHEDULED PERSON OR ORGANIZATION This endorsement modifies insurance provided under the following: BUSINESSOWNERS COVERAGE FORM SCHEDULE Name Of Additional Insured Person(s) Or Organization(s) Location(s) Of Covered Operations Information required to complete this Schedule, if not shown above, will be shown in the Declarations. Section II - Liability is amended as follows A. The following is added to Paragraph C. Who Is An Insured: 3. Any person(s) or organization(s) shown in the Schedule is also an additional insured, but only with respect to liability for "bodily injury", "property damage" or "personal and advertising injury" caused, in whole or in part, by: a. Your acts or omissions; or b. The acts or omissions of those acting on Your behalf; in the performance of your ongoing operations for the additional insured(s) at the location(s) designated above. However: a. The insurance afforded to such additional insured only applies to the extent permitted by law; and b. If coverage provided to the additional insured is required by a contract or agreement, the insurance afforded to such additional insured will not be broader than that which you are required by the contract or agreement to provide for such additional insured. B. With respect to the insurance afforded to these additional insureds, the following additional exclusions apply: This insurance does not apply to "bodily injury" or "property damage" occurring after: 1. All work, including materials, parts or equipment furnished in connection with such work, on the project (other than service, maintenance or repairs) to be performed by or on behalf of the additional insured(s) at the location of the covered operations has been completed; or 2. That portion of "your work' out of which the injury or damage arises has been put to its intended use by any person or organization other than another contractor or subcontractor engaged in performing operations for a principal as a part of the same project. BP 04 50 07 13 Copyright. Insurance Services Office, Inc., 2012 Page 1 of 2 0 C. With respect to the insurance afforded to these additional insureds, the following is added to Paragraph D. Liability And Medical Expenses Limits Of Insurance: If coverage provided to the additional insured is required by a contract or agreement, the most we will pay on behalf of the additional insured is the amount of insurance: 1. Required by the contract or agreement; or 2. Available under the applicable Limits Of Insurance shown in the Declarations; whichever is less. This endorsement shall not increase the applicable Limits Of Insurance shown in the Declarations. BP 04 50 07 13 Copyright, Insurance Services Office, Inc., 2012 Page 2 of 2 .,t-- 0111RORG