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HomeMy WebLinkAboutLIBERTY COMMON SCHOOL - INSURANCE CERTIFICATE (9)LIBER-8 OP ID: P5 ACORO` CERTIFICATE OF LIABILITY INSURANCE DATE 07/(05//017 Y) 2 017 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). PRODUCER CONTACT Karen E. Siwek, CPANAME: _ Brown & Brown Inc 4632 Boardwalk Dr, Suite 200 ac°ONr o Ext : 970-482-7747 ac No): 970-484-4165 Fort Collins, CO 80525 Karen E. Siwek, CPA -ADDRESS: ksiwek@bbcolorado.com INSURERS AFFORDING COVERAGE NAIC 9 INSURER A: Massachusetts Bay Ins Co 22306 INSURED Liberty Common School INSURER B: Pinnacol Assurance Company 41190 1725 Sharp Point Dr. INSURERC: Hanover Insurance Co. 22292 Fort Collins, CO 80525 INsuRERD:Allmerica Financial Benefit 41840 INSURER E: INSURER F : nnVFRAn FA r:FRTIFIr ATF NI IMRFR• RF\/ICIn KI All IMRFD• 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 TYPE OF INSURANCE ADDL UBRI POLICY EFF POLICY EXP LIMITS LTR D POLICY NUMBER MM/DD/YYYY MM/DD/YYYY A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,00 CLAIMS -MADE X OCCUR X ZH4-A957918 07/01/2017 07/01/2018 DAMAGE TO RENTED PREMISES Ea occurrence $ 100,00 X MED EXP (Any one person) $ 15,00 Educator Legal claims made PERSONAL & ADV INJURY $ 1,000,00 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,00 PRO- POLICY ❑ JECT LOC PRODUCTS - COMP/OP AGG $ Included Emp Ben. $ 1,000,00 OTHER: AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea accident $ 1,000,00 X BODILY INJURY (Per person) D ANY AUTO AW4-A957923 07/01/2017 07/01/2018 $ ALL OWNED SCHEDULED AUTOS AUTOS BODILY INJURY (Per accident) $ NON -OWNED HIRED AUTOS AUTOS PROPERTY DAMAGE Per accident $ X UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 10,000,00 AGGREGATE $ 10,000,00 C EXCESS LIAB CLAIMS -MADE UH4-A957920 07/01/2017 07/01/2018 DED X I RETENTION $ 0 $ KERS COMPENSATION EMPLOYERS' LIABILITY TBANYPROPRIETOR/PARTNER/EXECUTIVE Y / N OFFICER/MEMBER EXCLUDED? ❑ (Mandatory in NH) N / A 4046263 07/01/2017 07/01/2018 X PER OTH- STATUTE ER E.L. EACH ACCIDENT $ 500,00 E.L. DISEASE - EA EMPLOYEE $ 500,00 If yes, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT $ 500,00 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) Certificate holder is included as an additional insured on the general liability policy per HG 0001 0605 lhaVII1l2UU-IsIry ;Lei 414 19Lha4AGULei 0 CITYF11 City of Fort Collins Risk Management P O Box 508 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 Karen E. Siwek, CPA © 1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25 (2014/01) The ACORD name and logo are registered marks of ACORD LIBER-8 OP ID: P5 ,4CVRO' CERTIFICATE OF LIABILITY INSURANCE DATE 0705/05/2 Y7 `-� /017 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). PRODUCER CON NAMEACT Karen E. Siwek, CPA Brown & Brown Inc 4532 Boardwalk Dr, Suite 200 A/cCNo El): FAX No): 970-484-4165 Fort Collins, CO 80525 E-MAIL Karen E. Siwek, CPA ADDRESS: ksiwek@bbcolorado.com INSURERS AFFORDING COVERAGE NAIC # INSURER A: Massachusetts Bay Ins Co 22306 INSURED Liberty Common School 1725 Sharp Point Dr. Fort Collins, CO 80525 INSURER B : Pinnacol Assurance Company 41190 INSURER C : Hanover Insurance Co. 22292 INSURER D : Allmerica Financial Benefit 41840 INSURER E: INSURER F : C0VFRAr,FS CFRTIFICATF NIIMRFR• RFVICIr1N 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 TYPE OF INSURANCE A S L SUBR POLICY EFF POLICY EXP LIMITS LTR N WVD POLICY NUMBER MM/DDNYYY MM/DD/YYYY A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,00 CLAIMS -MADE )(1 OCCUR ZH4-A957918 07/01/2017 07/01/2018 DAMAGE TO RENTED PREMISES Ea occurrence)$ 100,00 X MED EXP (Any one person) $ 15,00 Educator Legal claims made PERSONAL & ADV INJURY $ 1,000,00 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,00 POLICY PRO- JECT 7 LOC PRODUCTS -COMP/OP AGG $ Included Emp Ben. $ 1,000,00 OTHER: AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea accident $ 1,000,00 X BODILY INJURY (Per person) _ $ D ANY AUTO AW4-A957923 07/01/2017 07/01/2018 ALL OWNED SCHEDULED AUTOS AUTOS BODILY INJURY (Per accident) $ PROPERTY dOaPERTnDAMAGE P $ NON -OWNED HIRED AUTOS AUTOS(Per X UMBRELLA LIAR X OCCUR EACH OCCURRENCE $ 10,000,00 _ AGGREGATE $ 10,000,00 C EXCESS LIAB CLAIMS -MADE UH4-A957920 07/01/2017 07/01/2018 DED X RETENTION $ 0 $ B WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE Y / N OFFICER/MEMBER EXCLUDED? (Mandatory in NH) N/A 4046263 07/01/2017 07/01 /2018 X PER OTH- STATUTE ER E.L. EACH ACCIDENT $ 500,00 E.L. DISEASE - EA EMPLOYEE -- $ 500,000 If yes, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT $ 500,00 i DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) RE: Liberty -to -Liberty 5K Run/Walk - The City of Fort Collins, its officers, agents, employees & volunteers are included as an additional insured if required by written contract per HG0001 0605 lh a C11 I I a LhG\ 1 a: Lei 411 q 9t101"q 4 Atli Lei 0 CITYFOR City of Fort Collins Risk Management P.O. Box 580 Fort Collins, CO 80522-0580 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 Karen E. Siwek, CPA © 1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25 (2014/01) The ACORD name and logo are registered marks of ACORD LIBER-8 OP ID: P5 .44cORO` �� CERTIFICATE OF LIABILITY INSURANCE ATE (MM/DD/YYYY) r07/05/2017 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). PRODUCER Brown & Brown Inc 4532 Boardwalk Dr, Suite 200 Fort Collins, CO 80525 CONTACT NAME: Kdren E. Siwek, CPA PHONE FAX A/c No Ext:970-482-7747 AIC No: 970-484-4165 E-MAIL ADDRESS: ksiwek@bbcolorado.com Karen E. Siwek, CPA INSURERS AFFORDING COVERAGE NAIC It INSURER A: Massachusetts Bay Ins Co 22306 INSURED Liberty Common School INSURER B : Pinnacol Assurance Company 41190 1725 Sharp Point Dr. Fort Collins, CO 80525 INSURER C : Hanover Insurance Co. 22292 41840 INSURER D : Allmerica Financial Benefit 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` UBRi I WVD POLICY NUMBER POLICY EFF MM/DD/YYYY POLICY EXP MM/DD/YYYY LIMITS A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,00 CLAIMS -MADE 1XI OCCUR X ZH4-A957918 07/01/2017 07/01/2018 DAMAGE TO RENTED PREMISES Ea occurrence $ 100,00 X MED EXP (Any one person) $ 15,00 Educator Legal claims made PERSONAL & ADV INJURY $ 1,000,00 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,00 POLICY PRO- JECT LOC PRODUCTS - COMP/OPAGG $ Included Emp Ben. $ 1,000,00 OTHER: AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea accident $ 1 000,00 , BODILY INJURY (Per person) $ D X ANY AUTO AW4-A957923 07/01/2017 07/01/2018 ALL OWNED SCHEDULED AUTOS AUTOS BODILY INJURY (Per accident) $ PROPERTY DAMAGE Per accident $ NON -OWNED HIRED AUTOS AUTOS X UMBRELLA LAB X OCCUR EACH OCCURRENCE $ 10,000,00 AGGREGATE $ 10,000,00 C EXCESS LIAB CLAIMS -MADE UH4-A957920 07/01/2017 07/01/2018 DED X RETENTION $ 0 $ B WORKERS COMPENSATION AND EMPLOYERS' LIABILITY N ANY PROPRIETOR/PARTNER/EXECUTIVE YIN 4046263 07/01/2017 07/01/2018 X PER OTH- STATUTE ER E.L. EACH ACCIDENT $ 500,00 OFFICER/MEMBER EXCLUDED? (Mandatory in NEI) N / A E.L. DISEASE - EA EMPLOYEE $ 600,00 If yes, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE -POLICY LIMIT 500 00 $ , DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) RE: Liberty Common High School Torch Trek The City of Fort Collins, its officers, agents, employees & volunteers are included as an additional insured if required by written contract per HG 0001 0605 L;tK I IFIL;A I t HULUtK I.AIVI.ti-LA I IUIV CITYFOR City of Fort Collins Risk Management P.O. Box 580 Fort Collins, CO 80522-0580 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 Karen E. Siwek, CPA © 1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25 (2014/01) The ACORD name and logo are registered marks of ACORD