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Home My WebLink About102925 MOUNTAIN STATES EMPLOYERS COUNCIL - INSURANCE CERTIFICATE (2)Client#: 1084940 MOUNTSTA15 ACORDTM CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DD/YYYY) 1 7/06/2017 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 USI Colorado, LLC Prof Liab CONTACT NAME: PHONE g00 873-8500 FAx A/C No Ext : (A C, No E-MAIL ADDRESS: INSURER(S) AFFORDING COVERAGE NAIC # P.O. Box 7050 Englewood, CO 80155 INSURER A: Travelers Indemnity Company of 125682 800 873-8500 INSURED Mountain States Employers Council, Inc. INSURER B: Travelers Indemnity Company 25658 41190 Pinnacol Assurance Company INSURER C : P Y 1799 Pennsylvania St. INSURERD: Indian Harbor Insurance Company 36940 Denver, CO 80203 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 CONTRACTOR 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'SUBR INSR WVD POLICY NUMBER _ POLICY EFF (MMIDD POLICY EXP MM/DD LIMITS A X COMMERCIAL GENERAL LIABILITY X X 6809E447455 7/15/2017 07/15/2018 $1,0�000 pEACCH�OECCURRENCE PREMISES ERENTED occE ence s300,000 CLAIMS -MADE � OCCUR MED EXP (Any one person) $ 5,000 PERSONAL & ADV INJURY $1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 $2,000,000 PRO- X POLICY FI JECT _ LOC $ OTHER: B _ AUTOMOBILE LIABILITY X X BA9E450078 7/15/2017 07/15/201 Ee ac. n INED SINGLE LIMIT $1,000,000 BODILY INJURY (Per person) $ X ANY AUTO BODILY INJURY (Per accident) $ ALL OWNED SCHEDULED AUTOS AUTOS X HIRED AUTOS X NON -OWNED AUTOS PROPERTY erraccidenDAMAGE $ B X UMBRELLA LIAB X OCCUR X x CUP9E450515 7/15/2017 07/1512018 EACH OCCURRENCE $$ 000 000 AGGREGATE EXCESS LIAB CLAIMS -MADE s8,000,000 DED TX RETENTION $10000 $ C WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE Y/ N OFFICER/MEMBER EXCLUDED? � (Mandatory in NH) N/A x 4046690 7/01/2017 07/01/201 X PERFP E.L. EACH ACCIDENT $1,000,000 E.L. DISEASE - EA EMPLOYEE $1,000,000 E.L. DISEASE - POLICY LIMIT $1,000,000 If yes, describe under DESCRIPTION OF OPERATIONS below D Professional MPP004161004 7/16/2017 07/15/201 Each Claim - $3,000,000 Liability Aggregate - $5,000,000 Claims Made Ded. Per Claim $50,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) If required by written contract or written agreement, the following provisions apply subject to the policy terms, conditions, limitations and exclusions: The Certificate Holder is included as Automatic Additional Insured's for ongoing and completed operations under General Liability; Designated Insured under Automobile Liability; and Additional Insured under Umbrella / Excess Liability but only with respect to liability arising out of the Named Insureds work performed on behalf of the certificate holder. This insurance (See Attached Descriptions) CERTIFICATE HOLDER GANI.tLLAI IUN City of Fort Collins SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Y THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Attn: Gerry Paul; Purchasing Dept. ACCORDANCE WITH THE POLICY PROVISIONS. P.O. Box 580 Fort Collins, CO 80522 AUTHORIZED REPRESENTATIVE © 1988-2014 ACORD GORPORAI ION. All ngnts reservea. ACORD 25 (2014/01) 1 of 2 The ACORD name and logo are registered marks of ACORD #S21080853/M21055526 RDSZP SAGITTA 25.3 (2014/01) 2 of 2 #S21080853/M21055526