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HomeMy WebLinkAboutSURE SHOT DRILLING INC - INSURANCE CERTIFICATE (2)ACORN® CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDDYYYY) 3/3/2016 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 Olson &Olson Ltd 5655 S Yosemite Street #200 Greenwood Village CO 80111 CONTACT NAME: A/CONNo EX :303-867-2 16 (FAX,iNo : 3- 7-2 74 EMAIL ADDREss:rhonda. a he ols n ndolson.c m INSURER(S) AFFORDING COVERAGE NAIC p INSURER A :Travelers Indemnity n 25658 INSURED SURES-2 INSURER B :Charter Oak Fire Ins CO 25615 INSURER C:Travelers Prop Cas Co of Amer 25674 Sure Shot Drilling, LLC INSURER D :Farmin ton Casualty Company 1483 Sure Shot Holdings, LLC 695 S Colorado Blvd. #440 Denver CO 80220 INSURER E : INSURER F : COVERAGES CERTIFICATE NUMBER: 1087336191 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 INSR SUBR WVD POLICY NUMBER POLICY EFF MM/DD/YYYY POLICY EXP MM/DD/YYYY LIMITS A GENERAL LIABILITY C05F464179 3/2/2016 3/2/2017 EACH OCCURRENCE $1,000,000 X COMMERCIAL GENERAL LIABILITY AMA E TO RENTED PREMISES Ea occurrence $300,000 CLAIMS -MADE 1XI OCCUR MED EXP (Any one person) $10,000 PERSONAL& ADV INJURY $1,000,000 GENERALAGGREGATE $2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP/OP AGG $2,000,000 $ POLICY PRO LOC B AUTOMOBILE LIABILITY BA5F464179 3/2/2016 3/2/2017 Ea accident LIMIT $1,000,000 X BODILY INJURY (Per person) $ ANY AUTO ALL OWNED SCHEDULED AUTOS AUTOS BODILY INJURY (Per accident) $ rPROPERTY DAMAGE Per accident $ NON -OWNED HIRED AUTOS AUTOS C UMBRELLA LIAB X OCCUR CUP5F464179 3/2/2016 3/2/2017 EACH OCCURRENCE $4,000,000 AGGREGATE $ EXCESS LIAB CLAIMS -MADE DED X I RETENTION $10,000 $ D WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y / N DTF UB8G78986-6-16 3/1/2016 3/1/2017 X WCSTATU- OTH- RY IMIT R ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? N❑ N/A E.L. EACH ACCIDENT $1,000,000 (Mandatory in NH) E.L DISEASE -EA EMPLOYEE $1,000,000 If yes, describe under DESCR!PTION OF C^EP.ATIONS below I E.L. DISEASE - POLICY LIMIT 1 $1,000,000 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required) Any state or political subdivision that has issued a license or permit to the Named Insured is included as an additional insured. Contractor's License. CERTIFICATE HOLDER CANCELLATION City of Ft Collins PO Box 580 Fort Collins CO 80522-0580 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 (;�.Irf4 © 1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25 (2010105) The ACORD name and logo are registered marks of ACORD