Loading...
HomeMy WebLinkAboutANTLER CONSTRUCTION COMPANY - INSURANCE CERTIFICATEA�COR" CERTIFICATE OF LIABILITY INSURANCE DATE (MMIDD1YYYY) 06/27/2017 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). PRODUCER CONTACT NAME: Pinnacol Assurance - - ......... .................... .....__ PHONE ...FAX 7501 E Lowry Blvd Arc N,_ o. Ext): Denver, CO 80230-7006 E-MAIL ADDRESS: 1NSURER(5IAFFORDINGCOVERAGE _ NAIC# — INSURER A: PlnnaC01 Assurance 41190 INSURED INSURER B : Antler Construction Company 546 Se 8th St Unit B4 - INSURER C : .._........... _..... -................ _........ _.... _.......---......_......_................................................. __..._..._......... Loveland, CO 80537 INSURER D: INSURER E : INSURER F : 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. 'INSR L.......... ..._. ............ ..... ......... ........,ADDLSUBR .... LTR TYPE OF INSURANCE IN ..._....... ... .......... ..........._.._. POLICY EFF POLICY EXP-..............................._.__................ ............. _...... _.... ._.._.........._. POLICY NUMBER MM/DDIYYYY MM/DDIYYYY UMITS COMMERCIAL GENERAL LIABILITY ..... EACH OCCURRENCE $ ,.._ ...,. CLAIMS MADE OCCUR _ ........_ .......... DAMAGE TO RENTED :PREMISES Ea occurrence,_,j,? _ _.,. .L,�_ - - MED EXP (Any one person) $ PERSONAL 8 AD.V INJURY Is GEN'L AGGREGATE. LIMIT APPLIES PER GENERAL AGGREGATE $ PRO - POLICY JECT LOC e PRODUCTS-COMPOPAGG $_ OTHER: ...__........................—........._..._......_............�_ _...-__.._._.___._.._.._......_ Is AUTOMOBILE LIABILITY Ir jE Iv9BINED SINGLE LIMIT $ a acc dentl .... . ........................... ...................... _......__......_._ ANY AUTO j BODILY INJURY (Per person) $ ......... ......... :.OWNED.. SCHEDULED _-._...... ) AUTOS ONLY 'AUTOS :BODILY INJURY (Per accident)' :$ HIRED NON -OWNED I PROPERTY DAMAGE S AUTOS ONLY AUTOS ONLY der accident UMBRELLA LI/SB OCCUR —, EACH OCCURRENCE 3 EXCESS LIAR CLAIMS -MADE .AGGREGATE i _...... $ DED RETENTION S S WORKERS COMPENSATION - PER OTH X i AND EMPLOYERS' LIABILITY YIN STATUTE Eft ANYPROPRIETOR/PARTNERtEXECUTIVE i A 4149254 07/01/2017 07/01/2018 E L EACH ACCIDENT I ,;$ 1,000,000 OFFICERtMEMBEREXCLUDEQ? Y❑ N/A: i (Mandatory in NH) I E.L.:DISEASE - EA EMPLOYEE 5 1,000,000 If yes describe under — --- — — -- DESCRIPTION OF OPERATIONS be!on E.L. DISEASE - POLICY LIMIT S 1,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101. Additional Remarks Schedule, may be attached if more space is required) Unless otherwise stated in the policy provisions, coverage is in Colorado only. Refer to the Acord 101 Additional Remarks Schedule for supplemental cancellation notification information. Excluded (If any) : Nicole Corlett, Nathan Corlett CERTIFICATE HOLDER CANCELLATION 1810842 City of Ft. Collins 330 S. Clollege Ave. PO Box 580 Fort Collins, CO 80522 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 Western Group, Inc/ Wheatridge ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD CERTIFICATE HOLDER COPY IMPORTANT If the certificate holder is an ADDITIONAL INSURED, the poiicy(ies) must be endorsed. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). 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). DISCLAIMER The Certificate of Insurance on the reverse side of this form does not constitute a contract between the issuing insurer(s), authorized representative or producer, and the certificate holder, nor does it affirmatively or negatively amend, extend or alter the coverage affordedby the policies listed thereon. DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT (CONT) 4CORD� AGENCY CUSTOMER ID: N/A LOC #: N/A annITIr)MAI RFMARK-q SC_NFn111 F AGENCY NAMED INSURED Western Group, Inc/ Wheatridge Antler Construction Company POLICY NUMBER 546 Se 8th St Unit B4 - 4149254 Loveland, CO 80537 CARRIER NAIL CODE Pinnacol Assurance 411901 EFFECTIVE DATE: 06/27/2017 THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, FORM NUMBER: Acord 21(2111/'PORM TITLE: Certificate of Liability Insurance Pane 1 of 4 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING COMPANY WILL ENDEAVOR TO NOTIFY 10 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO NOTIFY SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE COMPANY, ITS AGENTS OR REPRESENTATIVES. ACORD 101 (2008/01) © 2008 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD AFRO® CERTIFICATE OF LIABILITY INSURANCE °0627/2017 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). PRODUCER NAMEA Pinnacol Assurance _ PHONE FAX 7501 E Lowry Blvd ___No): 1wc No Extj ...._. _ (A/C, Denver, CO 80230-7006 ADDRIESS_ _ INSURERS) AFFORDING COVERAGE NAIC A INSURER A: Pinnacol Assurance 41190 INSURED INSURER B : Antler Construction Company 546 Se 8th St Unit B4 - INsuRERc: Loveland, CO 80537 INSURER D: INSURER E : INSURER F : 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. ....................................................._......_ ........................... .. ....._._.. . INSR _ _.............. .......... ........ ..--.ADDCSUBR ......... ._......... -: POLICY EFF •.....POLICY EXP LTR TYPE OF INSURANCE POLICY NUMBER MMIDDlYYYY MWDDIYYYY LIMBS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ CLAIMS -MADE !OCCUR ; DAMAGE TO I PREMISES(EaENTED occurrence)$ MED EXP (Any one person) ..... $ _..... - -- - ...... j PERSONAL & ADV INJURY ..... .......... ......._.._ $ GEN'L AGGREGATE LIMIT APPLIES PER'. ! GENERAL AGGREGATE $ POLICY ' PRO-LOC JECT --_.._ ..._.. _.. ... I 3 — _.._-------- PRODUCTS • COMPlOP AGG - — --- $ OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT (Ea agent) ............ ........... $ _..................................._........ _.._. I ANY AUTO j BODILY INJURY (Per person) $ O"VNED SCHEDJLED BODILY INJURY (Per accident) $ AUTOS ONLY AUTOS HIRED NON -OWNED PROPERTY DAMAGE $ AUTOS ONLY ; AUTOS ONLY % (Per accident) ...,.,.._.,,, $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ AGGREGATE ............................ ........._............................ $--- EXCESS LAB ! CLAIMS -MADE ._.__.._.._.�._.......................��....._....__..._...._.._............. � DED RETENTION S $ WORKERS COMPENSATION ! ' X STATUTE ERH AND EMPLOYERS' LIABILITY YY A ICER-MEMBERE NtAI 4149254 07/01/2017 07/01/2018 E.L.EACHACCIDENT $ 1,000,000 OF CLUDED7ECUTIVE (Mandatory In NM) i E.L. °tSEASE - EA EMPLOYEE $ 1,000,000 E.L. DISEASE - POLICY LIMIT $ 1,000,000 If yes. describe under . DESCRIPTION OF OPERATIONS belo�.v 3 I I ( DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) Unless otherwise stated in the policy provisions, coverage is in Colorado only. Refer to the Acord 101 Additional Remarks Schedule for supplemental cancellatio notification information. Excluded (If any) : Nicole Corlett, Nathan Corlett CFRTIFICATF 1401 DFR CANCELLATION 1810842 City of Ft. Collins 330 S. Clollege Ave. PO Box 580 Fort Collins, CO 80522 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 Western Group, Inc/ Wheatridge U 1y88-ZU15 AUUKU 1,UKFUKA I IUN. All rlgn[s reserveo. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD CERTIFICATE HOLDER COPY IMPORTANT If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). 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). DISCLAIMER The Certificate of Insurance on the reverse side of this form does not constitute a contract between the issuing insurer(s), authorized representative or producer, and the certificate holder, nor does it affirmatively or negatively amend, extend or alter the coverage afforded by the policies listed thereon. DESCRIPTION OF OPERATIONS/LOCATIONSNEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT (CONT) -�� ANTLE-6 OP ID: KR ACORL7' 7TE(MMIDD/WW) CERTIFICATE OF LIABILITY INSURANCE /27/2017 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). CONTACT PRODUCER Phone: 303-202-0082 NAME: Western Group Inc -Denver F2020086 PHONE FAX Fax: 303- - IC. No. Exci -- 6425 West 44th Ave (A: (A(C, No): PO BOX 497 E-MAIL ADDRESS: Wheatridge, CO 80034 Jim Howes INSURERS AFFORDING COVERAGE NAIC # _ INSURER A: United Security Insurance Co. 12537 INSURED Antler Construction, Co. INSURER B: Auto -Owners Insurance CO 18988 546 SE 8th Street,Unit B4 INSURERC: Loveland, CO 80537 INSURER D : INSURER E : INSURER F : r r%%1a0A!`CQ rCDTICIrATC III IIIARFD• RFVICInN NI IMRFR- 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 j TYPE OF INSURANCE ADDL SUBR POLICY NUMBERPOLICY EXP LTR MM/DDY/YYYY MM/DD/YYW LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 A X COMMERCIAL GENERAL LIABILITY BV01653821 08/01/2016 08/01/2017 DAMAGE TO RENTED PREMISES Ea occurrence $ 100 000 MED EXP (Any one person) $ 5,00 CLAIMS -MADE u OCCUR PERSONAL & ADV INJURY $ 1,000,00 $ 2,000,00 GEN'L AGGREGATE LIMIT APPLIES PER: �GENERALAGGREGATE PRODUCTS - COMP/OP AGG $ 2,000,00 Deductibl $ 5,00 POLICY X PRO LOC I B AUTOMOBILE LIABILITY ANY AUTO 4888439100 06/28/2017 06/28/2018 COMBINED SINGLE LIMIT Ea accident 1,000,000 BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ X ALL OWNED SCHEDULED AUTOS AUTOS X NON -OWNED X HIRED AUTOS AUTOS PROPERTYDAMAGE — $ Medical Payment — $ 10,00 UMBRELLA LIAB OCCUR EACH OCCURRENCE $ AGGREGATE $ EXCESS LIAB CLAIMS -MADE DED I I RETENTION $ $ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y / N ANY PROPRIETOR/PARTNER/EXECUTIVE WC STATU- OTH- TORY LIMITS I I ER E.L. EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? ❑ (Mandatory in NH) N / A E.L. DISEASE - EA EMPLOYEE $ E.L. DISEASE - FOUCY LIMIT ! If ge describe under DESCRIPTION OF OPERATIONS below I DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required) i rAMrm I ATIrIM CITYFTC SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. City of Fort Collins 330 S. College Ave. P.O. Box 580 AUTHORIZED REPRESENTATIVE I Jim Howes Fort Collins, CO 80522-0580 i U lytSB-LULU Ml.r lJ l[U Vvl[rvI[/111v19. MII Ilynl, ICDCIYCU. ACORD 25 (2010/05) The ACORD name and logo are registered marks of ACORD