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HomeMy WebLinkAboutPIERSON'S CONCRETE CONSTRUCTION CO - INSURANCE CERTIFICATE (9)P52ta N12rirN1! A FAE (MM/DD/YYYY) 1..r CERTIFICATE OF LIABILITY INSURANCE /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 1-303-534-4567 CONTACT NAME: ILIA, Inc. - Colorado Division PHONE FAX OVC. No. EX'): _--------__—_-- Alt No : E-MAIL denaccounttechs@imacorp.Com 1705 17th Street ADDRESS: _ -_ Suite 100 - ------INSURER( S AFFORDING COVERAGE NAIL9 Denver, CO 80202 _ _ INSURER A: PINK&C_OL ASSUR 41190 INSURED INSURER B: _ Pierson's Concrete Construction Co. INSURER C PO Box 271248 INSURERD: INSURER E : Fort Collins, CO 80527 1 INSURERF: 11n%1raAr1_oe rGormira'rr Laiunro- 9nww;( .nri RFVISInN tJIIMRFR- 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 SUER POLICY NUMBER MMIDDPOLICY EFF POLICY IYYYY MMIDDr EXP LIMITS LTR COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ _ CLAIMS -MADE 0 OCCUR DAMAGE TO RENTED PREMISES Ea occu ante $ MED EXP (Any one person) f PERSONAL 8 ADV INJURY $ GENERAL AGGREGATE GENT AGGREGATE LIMIT APPLIES PER: S PRODUCTS - COMP/OP AGG POLICY I I JECT LOC $ OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT (Ea accident) $ BODILY INJURY (Per person) ANY AUTO $ BODILY INJURY (Per accident) ALL OWNED SCHEDULED AUTOS AUTOS $ PROPERTY DAMAGE Peraccldent _ _ NON -OWNED HIRED AUTOS _ AUTOS $ S UMBRELLA LIAB OCCUR EACH OCCURRENCE $ AGGREGATE $ EXCESS LIAR CLAIMS -MADE DED RETENTION $ $ A WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANY PROPRIETOR/PARTNERIEXECUTIVE a OFFICER/MEMBER EXCLUDED? (Mandatory in NH) N I A 4055614 07/01/17 07/01/18 PER UTE ERH -----------_-- $ 1,000,000 $ 1,000,000 __% E.L. EACH ACCIDENT _ E.L. DISEASE - EA EMPLOYEE E.L. DISEASE - POLICY LIMIT If yes, describe under DESCRIPTION OF OPERATIONS below I I E 1,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) UtK I II-IUA It HULUtK %,Ar4%,LLLA 11UIV SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE City of Fort Collins THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. PO Box 1190 AUTHORIZED REPRESENTATIVE n Fort Collins CO 80522 USA U 1988-2014 AUOKU UOKPUKA I IUN. All rights reserved. ACORD 25 (2014/01) The ACORD name and logo are registered marks of ACORD spmaestas 50306200 Cl) N z LU P326012FAW P1NN/ICOL ASSURANCE Pierson's Concrete Construction Inc PO Box 271248 Fort Collins, CO 80527 ENDORSEMENT: Blanket Waiver of Subrogation NCCI #: WC000313B Policy #: 4055614 IMA, Inc 1705 17th Street Suite 100 Denver, CO 80202 (303) 534-4567 7501 E Lowry Blvd Denver, CO B0230-7006 303-361-4000 P 800-873-7242 www pinnacol coin We have the right to recover our payments from anyone liable for an injury covered by this policy. We will not enforce our right against the person or organization named in the Schedule. This agreement applies only to the extent that you perform work under a written contract that requires you to obtain this agreement from us. This agreement shall not operate directly or indirectly to benefit anyone not named in the Schedule. SCHEDULE To any person or organization when agreed to under a written contract or agreement, as defined above and with the insured, which is in effect and executed prior to any loss. Effective Date.July 1, 2017 Expires on: July 1, 2018 Pinnacol Assurance has issued this endorsement July 3, 2017 7501 E Lowry Blvd Denver, CO 80230-7006 Page 1 of 1 P ISA 07103/2017 18 38 38 4055614 49454924 359-8 �P526002tMN12 r `...,�.,� DATE (MMIDDIYYYY) A a.....l.11lf.J CERTIFICATE OF LIABILITY INSURANCE 07/06/2017 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 1-303-534-4567 CONTACT NAME: _ IMA, Inc. - Colorado Division PHONE - FAX LAIC. Na E_AU: E-MAIL denaccountteahsgimac0 Com 1705 17th Street ADDRESS _ �._ Suite 100 INSURERS) AFFORDING COVERAGE NAIC N Denver, CO 80202 INSURERA: UNITED SPECIALTY INS CO (R-T Specialty) 12537 INSURED INSURER B: EMPLOYERS NUT CAS CO 21415 Pierson•s Concrete Construction Co. INSURER CPINNACOL ASSUR 41190 PO Box 271248 INSURERD: INSURER E : Fort Collins, CO 80527 IINSURERF rnvcoAccc rCOTICIrATC MIMING r-0- Snin6n'i7 RFVICI0N NIIMRFR- 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 ADDL SUBR POLICY EFF POLICY EXP LIMITS LTR TYPE OF INSURANCE POLICY NUMBER MMIDD MMIDDIYYYY A X COMMERCIAL GENERAL LIABILITY ATNATL1760262 04/10/17 04/10/18 EACH OCCURRENCE $ 1,000,000 CLAIMS -MADE Ix I OCCUR TED -DAMAGE TO PREM!j a oNcu ence $ 50,000 X MED EXP (Any one person) $ Excluded BI/PD Ded: $5, 000 PERSONAL & ADV INJURY $ 1,000,000 AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 G_E_NI PRODUCTS - COMPIOP AGG $ 2.000, 000 _ POLICY f X J ECT L_ 1 LOC $ OTHER B AUTOMOBILE LIABILITY 5X4544718 04/10/17 04/10/18 COMBINED SINGLE LIMIT Ea accident $ 1,000,000 BODILY INJURY (Per person) $ X ANY AUTO BODILY INJURY (Per accident) $ ALL OWNED I SCHEDULED AUTOS AUTOS NON -OWNED X HIRED AUTOS X AUTOS PROPERTY DAMAGE JRer accident) $ A UMBRELLALIAS B OCCUR BTN1763825 04/10/17 04/10/18 EACH OCCURRENCE $ 2,000,000 AGGREGATE $ 2,000,000 X EXCESS LIAB CLAIMS -MADE DIED I I RETENTIONS $ C WORKERSCOMPENSATION AND EMPLOYERS' LIABILITY ANY PROPRIETORIPARTNEWEXECUTIVE � OFFICER/MEMBER EXCLUDED? (Mandatory In NH) N I A 4055614 07/01/17 07/01/18 X PER OTH- STATUTE ER $ 1,000,000 -- E.L. EACH ACCIDENT E.L. DISEASE - EA EMPLOYEE $ 1, 000, 000 E.L. DISEASE - POLICY LIMIT Ifyes, describe under DESCRIPTION OF OPERATIONS below $ 1, 000, 000 I DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space Is required) City of Fort Collins: for Pierson?s Concrete Summer BBQ 2017 City of Fort Collins is included as Additional Insured on the General Liability Policy if required by written contract or agreement and with respect to work performed by insured subject to the policy terms and conditions. I,tK I Ir K.A I t nULUrK \.MI\I,GILM I IV I\ SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE City of Fort Collins THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. PO Box 1190 AUTHORIZED REPRESENTATIVE Fort Collins , CO 80522 U3A C// /"& U 19UB-2014 ACORD CUKPUKA I IUN. All ngnts reservea. ACORD 25 (2014/01) The ACORD name and logo are registered marks of ACORD splaaestas 50306037 P5261N128(X)2 POLICY NUMBER: ATNATL1760262 Effective 04/10/17 - 04/10/18 COMMERCIAL GENERAL LIABILITY CG 20 37 07 04 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED — OWNERS, LESSEES OR CONTRACTORS — COMPLETED OPERATIONS This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Name Of Additional Insured Person(s) Or. Organization(s): Location And Description Of Completed Oper- ations When required by written contract Information required to complete this Schedule, if not shown above, will be shown in the Declarations. Section II — Who Is An Insured is amended to include as an additional insured the person(s) or organization(s) shown in the Schedule, but only with respect to liability for "bodily injury" or "property damage" caused, in whole or in part, by 'your work" at the location designated and described in the schedule of this endorsement performed for that additional insured and in- cluded in the "products -completed operations hazard". CG 20 37 07 04 © ISO Properties, Inc., 2004 Page 1 of 1