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BUILDER SERVICES GROUP INC DBA MATO - INSURANCE CERTIFICATE (9)
A�RD CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) 06„2/2017 I 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 Aon Risk services Central, Inc. Southfield MI office CONTACT NAME: (A/CNNo. Ext): (866) 283-7122 FAX No.): (800) 363-0105 E-MAIL ADDRESS: 3000 Town Center suite 3000 Southfield MT 48075 USA INSURER(S) AFFORDING COVERAGE NAIC # INSURED INSURER A: Old Republic Insurance Company 24147 Builder Services Group, Inc. INSURER B: ACE American Insurance Company 22667 d/b/a Mato A TopBuild Company INSURER C: Lloyds syndicate No. 1969 AA1120106 INSURER D: 4850 Lima Street Denver Co 80239 USA INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: 570066866739 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 ADOL I INSD UBR WVD POLICY NUMBER POLICY Y FF MMfDD/YYYY POLICY MM/DD/YYYY LIMITS A X COMMERCIAL GENERAL LIABILITY MWZY3104SS EACH OCCURRENCE $2,000,000 CLAIMS -MADE X❑ OCCUR DAMAGE TORENTED $2,000,000 PREMISES Ea occurrence MED EXP (Any one person) $25 , 000 PERSONAL &ADV INJURY $2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER GENERAL AGGREGATE $4 , 000 , 000 POLICY ❑ PRO X JECT ❑ LOC PRODUCTS - COMP/OP AGG $4,000,000 OTHER: A AUTOMOBILE LIABILITY MWTB 3104S4 06/30/2017 06/30/2018 COMBINED SINGLE LIMIT Ea accident $5,000,000 BODILY INJURY ( Per person) X ANY AUTO BODILY INJURY (Per accident) OWNED SCHEDULED AUTOS ONLY AUTOS PROPERTY DAMAGE HIRED AUTOS NON -OWNED Per accident ONLY AUTOS ONLY C X UMBRELLA LIAB X OCCUR CSUSA1701330 06/30/2017 06/30/2018 EACH OCCURRENCE $2,000,000 EXCESS LIAB CLAIMS -MADE AGGREGATE $2,000,000 DED RETENTION B WORKERS COMPENSATION AND WLRC48032461 06/30/2017 06/30/2018 X PER OTH- STATUTE I ER EMPLOYERS' LIABILITY YIN All Other States E.L. EACH ACCIDENT $1,000,000 B ANY PROPRIETOR / PARTNER /EXECUTIVE N/A sCFC48032473 06/30/2017 06/30/2018 OFFICER/MEMBEREXCLUDED? (Mandatory in NH) WI Only E.L. DISEASE -EA EMPLOYEE $1,000,000 If yes, describe under DESCRIPTION OF OPEPATIONS b=lam., E.L. DISEASE -POLICY LIMIT $1,000,000 B Excess WC wCUC48032485 06/30/2017 06/30/2018 EL Each Accident $1,000,000 WA Only EL Disease - Policy $1,000,000 SIR applies per policy ter s & condi ions EL Disease - Ea Emp $1,000,000 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) [Pro]: RE: Project Name: First Principle Homes Inc.]. CERTIFICATE HOLDER CANCELLATION 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 Ft. Collins AUTHORIZED REPRESENTATIVE Attn: Insurance Administration Bldg B 300 Laporte Ave�K��! Fort Collins Co 80521-2719 USA 0 cc d w C Q d7 B 0 2 rn oo oo 0 0 Lo Lo ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD