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HomeMy WebLinkAboutCORRESPONDENCE - RFP - 7671 BENEFITS - LIFE, DISABILITY & FAMILY MEDICAL LEAVE ADMINISTRATION (2)The ACORD name and logo are registered marks of ACORD CERTIFICATE HOLDER © 1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25 (2014/01) AUTHORIZED REPRESENTATIVE CANCELLATION CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DD/YYYY) JECT LOC POLICY PRO- GEN'L AGGREGATE LIMIT APPLIES PER: CLAIMS-MADE OCCUR COMMERCIAL GENERAL LIABILITY PREMISES (Ea occurrence) $ DAMAGE TO RENTED EACH OCCURRENCE $ MED EXP (Any one person) $ PERSONAL & ADV INJURY $ GENERAL AGGREGATE $ PRODUCTS - COMP/OP AGG $ DED RETENTION $ CLAIMS-MADE OCCUR $ AGGREGATE $ UMBRELLA LIAB EACH OCCURRENCE $ EXCESS LIAB DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) INSR LTR TYPE OF INSURANCE POLICY NUMBER POLICY EFF (MM/DD/YYYY) POLICY EXP (MM/DD/YYYY) LIMITS PER STATUTE OTH- ER E.L. EACH ACCIDENT E.L. DISEASE - EA EMPLOYEE E.L. DISEASE - POLICY LIMIT $ $ $ ANY PROPRIETOR/PARTNER/EXECUTIVE If yes, describe under DESCRIPTION OF OPERATIONS below (Mandatory in NH) OFFICER/MEMBER EXCLUDED? WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y / N AUTOMOBILE LIABILITY ANY AUTO ALL OWNED SCHEDULED HIRED AUTOS NON-OWNED AUTOS AUTOS AUTOS COMBINED SINGLE LIMIT BODILY INJURY (Per person) BODILY INJURY (Per accident) ACORD 101 (2008/01) The ACORD name and logo are registered marks of ACORD © 2008 ACORD CORPORATION. All rights reserved. THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, FORM NUMBER: FORM TITLE: ADDITIONAL REMARKS ADDITIONAL REMARKS SCHEDULE Page of AGENCY CUSTOMER ID: LOC #: AGENCY CARRIER NAIC CODE POLICY NUMBER NAMED INSURED EFFECTIVE DATE: Carrier: Illinois National Insurance Company� � Carrier: New Hampshire Insurance Company � � 2 2 Carrier: New Hampshire Insurance Company � Policy No. WC020765111 (NJ, PA)� Atlanta Carrier: New Hampshire Insurance Company � Policy No. WC020765110 (IL, KY,NC,NH,UT)� � Effective Date: 05/30/2016 - 05/30/2017� �� �� � Workers Compensation Continued:� Certificate of Liability Insurance �� J01525 Effective Date: 05/30/2016 - 05/30/2017� Policy No. WC020765108 (FL) � Effective Date: 05/30/2016 - 05/30/2017� Effective Date: 05/30/2016 - 05/30/2017� Policy No. WC020765112 (MA, ND, OH, WA, WI,WY) � � *MARSH USA, INC.� 230 Park Avenue� Voya Financial, Inc.� New York, NY 10169 � 25 � PROPERTY DAMAGE $ $ $ $ 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. INSD ADDL WVD SUBR N / A $ $ (Ea accident) (Per accident) OTHER: 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). COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: INSURED PHONE (A/C, No, Ext): PRODUCER ADDRESS: E-MAIL FAX (A/C, No): CONTACT NAME: NAIC # INSURER A : INSURER B : INSURER C : INSURER D : INSURER E : INSURER F : INSURER(S) AFFORDING COVERAGE SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. 2,000,000 05/30/2017 GL1721754 Ronald A. Santaniello X WC020765107 (CA) ATL-004044106-02 X 1,000,000 WC020765109 (AZ) X 19445 of Marsh USA Inc. ATLANTA, GA 30326 N 05/30/2016 X COMP/COLL $1,000 DED 2,000,000 Contractual Liab. Coverage 05/30/2016 05/30/2017 C CA3940556 (AOS) A 5,000,000 2,000,000 X *WC Continued on Attached* 23809 National Union Fire Insurance Co. of Pittsburgh, PA 1,000,000 X X 11/08/2016 05/30/2016 05/30/2016 City of Fort Collins is included as additional insured on the above general and auto liability policies, where required by written contract but only with respect to liability arising out of the operations of the named insured. Host Liquor is included X 05/30/2016 P.O. Box 580 Fort Collins, CO 80522 City of Fort Collins X B B Granite State Insurance Co J01525-Voya-AMER-16-17 5,000 05/30/2017 2,000,000 05/30/2017 A CA3940557 (MA) 23841 250,000 1,000,000 X WC020765106 (AOS) TWO ALLIANCE CENTER *MARSH USA, INC. 3560 LENOX ROAD, SUITE 2400 230 Park Avenue Voya Financial, Inc. New York, NY 10169 05/30/2016 215 N. Mason St., 2nd Floor X A X 05/30/2017 05/30/2017 New Hampshire Insurance Company