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HomeMy WebLinkAbout539869 LIGHTFIELD ENTERPRISES INC - INSURANCE CERTIFICATE (21)04/20/2017 Security Insurance Group, LLC 8219 W 20th St, Ste A Greeley, CO 80634 Tad Borrett 970-378-4818 970-378-4820 sig@securityinsurancegroup.net 00000000-949594 71 Lightfield Enterprises, Inc; Lightfield Properties, LLC 2600 Midpoint Dr Fort Collins, CO 80525 First Mercury Insurance Company A X Y Y WA-CGL-0000072619-01 04/21/2017 04/21/2018 X X 1,000,000 50,000 1,000,000 2,000,000 2,000,000 Auto Owners Insurance 32700 B Y Y 5033346600 04/21/2017 04/21/2018 X X X 1,000,000 First Mercury Insurance Company A X Y Y CAEX0000053666-03 04/21/2017 04/21/2018 X X 10,000 1,000,000 1,000,000 Pinnacol Assurance C Y 4173268 05/01/2017 05/01/2018 N X 1,000,000 1,000,000 1,000,000 Project: BID NO. 8344 Concrete Maintenance Project Phase III If required by written agreement, the certificate holder is included as additional insured for ongoing operations under general liability and auto liability. City of Fort Collins Purchasing Division 2nd Floor 215 N Mason Fort Collins, CO 80524 (TCB) Printed by TCB on April 20, 2017 at 11:42AM ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? INSR ADDL SUBR LTR INSD WVD DATE (MM/DD/YYYY) PRODUCER CONTACT NAME: PHONE FAX (A/C, No, Ext): (A/C, No): E-MAIL ADDRESS: INSURER A : 7501 E Lowry Blvd Denver, CO 80230-7006 303-361-4000 / 800-873-7242 www.pinnacol.com Lightfield Enterprises Inc 2600 Midpoint Drive Fort Collins, CO 80525 ICA/Security Insurance Group LLC 8219 W. 20th St. Greeley, CO 80634 (970) 378-4818 7501 E Lowry Blvd Denver, CO 80230-7006 Page 1 of 1 P MILLERS - Underwriter 04/19/2017 20:54:53 4173268 48950323 359-B NCCI #: WC000313B Policy #: 4173268 ENDORSEMENT: Blanket Waiver of Subrogation Effective Date: May 1, 2017 Expires on: May 1, 2018 Pinnacol Assurance has issued this endorsement April 19, 2017. Diversified Center of Excellence Phone (303) 361-4200 / (866) 820-6129 Fax (303) 361-5200 / (888) 329-2216 We have the right to recover our payments from anyone liable for an injury covered by this policy. We will not enforce our right against the person or organization named in the Schedule. This agreement applies only to the extent that you perform work under a written contract that requires you to obtain this agreement from us. This agreement shall not operate directly or indirectly to benefit anyone not named in the Schedule. SCHEDULE To any person or organization when agreed to under a written contract or agreement, as defined above and with the insured, which is in effect and executed prior to any loss. INSURED INSURER B : INSURER C : INSURER D : INSURER E : INSURER F : POLICY NUMBER TYPE OF INSURANCE POLICY EFF POLICY EXP LIMITS (MM/DD/YYYY) (MM/DD/YYYY) AUTOMOBILE LIABILITY UMBRELLA LIAB EXCESS LIAB WORKERS COMPENSATION AND EMPLOYERS' LIABILITY DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) AUTHORIZED REPRESENTATIVE EACH OCCURRENCE $ DAMAGE TO RENTED CLAIMS-MADE OCCUR PREMISES (Ea occurrence) $ MED EXP (Any one person) $ PERSONAL & ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ POLICY PRO- LOC PRODUCTS - COMP/OP AGG $ JECT OTHER: $ COMBINED SINGLE LIMIT $ (Ea accident) ANY AUTO BODILY INJURY (Per person) $ OWNED SCHEDULED BODILY INJURY (Per accident) $ AUTOS ONLY AUTOS HIRED NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY AUTOS ONLY (Per accident) $ OCCUR EACH OCCURRENCE $ CLAIMS-MADE AGGREGATE $ DED RETENTION $ $ PER OTH- STATUTE ER E.L. EACH ACCIDENT $ E.L. DISEASE - EA EMPLOYEE $ If yes, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT $ INSURER(S) AFFORDING COVERAGE NAIC # COMMERCIAL GENERAL LIABILITY Y / N N / A (Mandatory in NH) SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. 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. 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 have ADDITIONAL INSURED provisions or 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: CERTIFICATE HOLDER CANCELLATION © 1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD CERTIFICATE OF LIABILITY INSURANCE