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HomeMy WebLinkAboutTROY FORMING CONCRETE INC - INSURANCE CERTIFICATE (5)A 0RIY CERTIFICATE OF LIABILITY INSURANCE MMIDDNYY FDATE(1/2016 Y) 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 Sandra Thomas, CIC NAME: Moody Insurance Agency, Inc. 8055 East Tufts Avenue Via° N EM): (303) 824-6600A/C No. (303)370-0118 E-MAIL sthomas@mood ins.com ADDRESS: y INSURERS AFFORDING COVERAGE NAIC# Suite 1000 INSURERA:Kni ht Specialty Insurance Company 15366 Denver CO 80237 INSURED INSURERB:American Select Insurance Co 19992 INSURERC:Pinnacol Assurance 41190 Troy Forming Concrete, Inc. INSURERD: Denver Caisson Drilling, Inc. INSURERE: 998 Salida Way INSURER F: Aurora CO 80011 COVERAGES CERTIFICATE NUMBER: 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. LTR TYPE OF INSURANCE A L 5U R POLICY NUMBER MM/DD/YYYPOLICY Y XP MM/DDnYYY LIMITS A X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE X OCCUR KSVENA160051901 4/1/2016 4/1/2017 EACH OCCURRENCE $ 1,000,000 DAMAGE TO RENTED PREMISES Ea occurrence $ 50,000 MED EXP (Any one person) $ Excluded PERSONAL & ADV INJURY $ 1,000,000 GEN'L R[�] AGGREGATE LIMIT APPLIES PER: POLICY JET LOC OTHER: GENERAL AGGREGATE $ 2,000,000 PRODUCTS - COMP/OP AGG $ 2,000,000 Per Proj Agg Limit 5 $ See End B AUTOMOBILE LIABILITY ANY AUTO ALL OWNED SCHEDULED AUTOS AUTOS NON -OWNED HIRED AUTOS AUTOS CMU784429 4/1/2016 4/1/2017 EOMaBIINdEeD SINGLE LIMIT $ 1,000,000 X BODILY INJURY (Per person) $ BODILY INJURY Per accident ( ) $ PROPERTY DAMAGE Per accident $ Medical payments $ 5,000 UMBRELLA LIAB EXCESS LIAR OCCUR CLAIMS -MADE EACH OCCURRENCE $ AGGREGATE $ DED I I RETENTION $ $ C WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y / N ANY PROPRIETOPJPARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? ❑ (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below N/A 4103394 4/1/2016 4/1/2017 X OTH- STATUT ER E.L. EACH ACCIDENT $ 1,000,000 E.L. DISEASE - EA EMPLOYEE $ 1,000,000 E.L. DISEASE - POLICY LIMIT $ 1,000,000 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) CERTIFICATE HOLDER CANCELLATION City of Fort Collins P.O. Box 580 Fort Collins, CO 80521 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 S Thomas, CIC/SANTHO ACORD 25 (2014/01) NS025 (201401) ©1988-2014 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD