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HomeMy WebLinkAboutBLACK TIMBER BUILDERS LLC - INSURANCE CERTIFICATE (9)BLACK-3 OP ID: PB AC7"�Ro. CERTIFICATE OF LIABILITY INSURANCE D 07/11TE /2017Y) 07/11 /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 endorsements . PRODUCER Madison Insurance Group 600 S. Cherry Street, #900 Denver, Sharma Jamsay CONTACT NAME: Paula Blohm PHONE FAX ac No Ext : 303-322-0800 AIc No): 303-322-0874 a SS, pblohm@madisoninsurance.net DRRE INSURERS AFFORDING COVERAGE NAIC # INSURER A:Pinnacol Assurance Company 41190 INSURED Black Timber Builders, LLC Kyle Meyer 219 E. Elizabeth St. INSURER B:Colony Insurance Company 39993 INSURER C : INSURER D : Fort Collins, CO 80524 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 LTR TYPE OF INSURANCE ADDL N D UBR WV POLICY NUMBER POLICY EFF MM/DD/YYYY POLICY EXP MMIDDIYYYY LIMITS B X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE A] OCCUR 103 GLOO14825-00 07/12/2017 07/12/2018 EACH OCCURRENCE $ 1,000,00 AMA E RENTE PREMISES Ea occurrence $ 100,00 MED EXP (Any one person) $ 5,00 GEN'L PERSONAL 8 ADV INJURY $ 1,000,00 AGGREGATE LIMIT APPLIES PER: POLICY PRO- JECT LOC OTHER: GENERAL AGGREGATE $ 2,000,00 PRODUCTS - COMP/OP AGG $ 2,000,000 $ AUTOMOBILE LIABILITY ANY AUTO ALL OWNED SCHEDULED AUTOS AUTOS NON -OWNED HIREDAUTOS AUTOS L I NOT WITH MADISON COMBINED SINGLE LIMIT Ea accident $ BODILY INJURY (Per person) $ BODILY INJURY Per accident ( ) $ PROPERTY DAMAGE Peraccident $ $ UMBRELLA LIAB EXCESS LIAB OCCUR CLAIMS -MADE EACH OCCURRENCE $ AGGREGATE $ DED RETENTION$ $ A WORKERS COMPENSATION EMPLOYERS' LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE YIN OFFICER/MEMBER EXCLUDED? ❑ (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below N I A 4190143 03/01/2017 03/01/2018 STATUTE STA X TUTE ER E.L. EACH ACCIDENT $ 100,000 E.L. DISEASE - EA EMPLOYEE $ 100,00 E.L. DISEASE - POLICY LIMIT $ 500,00 DESCRIPTION OF OPERATIONS I LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) L AIN%,rLLA I IUIV CITFTC2 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN The City of Fort Collins ACCORDANCE WITH THE POLICY PROVISIONS. P.O. Box 580 Fort Collins, CO 80522 AUTHORIZED REPRESENTATIVE ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25 (2014101) The ACORD name and logo are registered marks of ACORD