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HomeMy WebLinkAbout310036 BLUE DOT SOLUTIONS INC - INSURANCE CERTIFICATE (18)ACORL?r CERTIFICATE OF LIABILITY INSURANCE DATE(M12/17YYY) 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 endorsements . PRODUCER Aon Risk Services, Inc of Florida CONTACT NAME: Aon Risk Services, Inc of Florida PHONE I FAX AIC No, Ext : 800-743-8130 A/C Noy 800-522-7514 1001 Brickell Bay Drive, Suite #1100 Miami, FL 33131-4937 EMAIL ADDRESS: ADP COI.Center@Aon.com INSURER(S) AFFORDING COVERAGE NAIC # INSURER A: New Hampshire Ins Co 23341 INSURED ADP TotalSource FL XI, Inc. INSURER B : INSURER C : 10200 Sunset Drive Miami, FL 33173 ALTERNATE EMPLOYER INSURER D: Blue Dot Solutions, Inc 1120 Lincoln Street, Suite 1507 INSURER E INSURER F Denver, CO 80203 COVERAGES CERTIFICATE NUMBER: 1300411 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. LIMITS SHOWN ARE AS REQUESTED. INSR LTR TYPE OF INSURANCE ADDL INSR SUBR WVD POLICY NUMBER POLICY EFF MM/DD/YYYY POLICY EXP MM/DD/YYYY LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ DAMAGE TO RENTED CLAIMS -MADE ❑OCCUR PREMISES (Ea occurrence) $ MED EXP (Anyone erson $ PERSONAL & ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ POLICY ❑ PROJECT ❑ LOC PRODUCTS - COMP/OP AGG $ S OTHER CMINED SINGLE LIMIT AUTOMOBILE LIABILITY Ea accident $ BODILY INJURY Perperson) $ ANY AUTO OWNED SCHEDULED AUTOS ONLY AUTOS BODILY INJURY (Per accident) $ PROPERTY DAMAGE HIRED NON -OWNED AUTOS ONLY AUTOS ONLY Per accident $ $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ AGGREGATE $ EXCESS LIAB CLAIMS -MADE DEC RETENTION $ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY YIN X I PER STATUTE OTH- ER EL, EACH A.CCOENT 2000.000 ANY PROPRIETOR,PARTNFRlEXECUTIVE I OFFICER/MEMBER EXCLUDED? NIA '%IVC 061139697 CO I 711 r?015 6/1/2017 E.L. DISEASE - EA EMPLOYEEI $ 2.000,000 (Mandatory in NH) I If yes, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT 1 $ 2,000,000 WORKERS' COMPENSATION & EMPLOYERS' LIABILITY COVERAGE FOR Blue Dot Solutions, Inc TERMINATED EFFECTIVE 6/1/2017 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) All worksite employees working for BLUE DOT SOLUTIONS, INC, paid under ADP TOTALSOURCE, INC.'s payroll, are covered under the above stated policy. BLUE DOT SOLUTIONS, INC is an alternate employer under this policy. CERTIFICATE HOLDER CANCELLATION CITY OF FORT COLLINS SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE ATTN: JIM HUME THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN PURCHASING DEPARTMENT ACCORDANCE WITH THE POLICY PROVISIONS. P. 0, BOX 580 FT. COLLINS, CO 80522 AUTHORIZED REPRESENTATIVE / ._#' OR L3lC { !' CVlCt!9, qnC C f CR6,tida ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 26 (2016103) The ACORD name and logo are registered marks of ACORD