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HomeMy WebLinkAbout130469 THE BRENDLE GROUP INC - INSURANCE CERTIFICATE (17)AcoRrj' CERTIFICATE OF LIABILITY INSURANCE ( DATE (MMIDDIY 07/17/2017YYY) 1 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 CONTACT NAME: Pinnacol Assurance PHONE FAX 7501 E Lowry Blvd Arc No. Ext): (Arc, No): Denver, CO 80230-7006 E-MAIL ADDRESS: tNSURERI(S) AFFORDING COVERAGE NAIC# INSURER A: PIrIr1aC01 Assurance 41190 INSURED����������.._ INSURERS �� The Brendle Group Inc 212 W Mulberry St INsuRERC: I Fort Collins, CO 80521 INSURER D: ........................................... _......... _.... .................... -........... ....... _......._.-........... ...... ................................ ...................................... _--------------- ..-------.._................. INSURER E : I . ................... ._...---.............. ............._..............................._.............................................. ...... _....... .._......................... ..._... INSURER F : } COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS 1S 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.,. ........ ......... ADDR POLICY EFF POLICY EXP....- LTR TYPE OF INSURANCE INS USUBPOLICY NUMBER MM/DDIYYYY MMIDDIYYYY ..........................................._..........._.._........_.......... .... ........ I.._._ ................. LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ CLAIMS -MADE OCCUR '^ . _.g.... _........ ___...... .... .._........ ............... DAb7AG£ TO RENTEO PREMISES (Ea_occurrence)$ _ME_D EXP (Any one person) S PERSONAL & ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER. GENERAL AGGREGATE S POLICY IPRO- ' LOC ............. SECT ...... _ PRODUCTS COMPfOP AGG $ ........................................ ......................................... .......... ...._.... .:._.:.................. ' OTHER $ AUTOMOBILE LIABILITY ` COMBINED SINGLE LIMIT - {Ea accident ANY AUTO BODILY INJURY (Per person) $ OWNED SCHEDULED BODILY INJURY Per acadertl )-' $ AUTOS ONLY '.. AUTOS ( HIRED NON -OWNED i PROPERTY DAMAGE $ AUTOS ONLY AUTOS ONLY ; JPet accident Is UMBRELLA LlAB _OCCUR EACH OCCURRENCE S ... EXCESS LIAR CLAIMS MADE; ....... ... ..... ..... ._......_ ......... AGGREGATE is _— _....__._. .. .............. DED ! RETENTION S S WORKERS COMPENSATION X PER OTH ' AND EMPLOYERS' LIABILITY Y / N STATUTE(ER ................................................. A ANYPROPRIETORlPARTNER EXECUTIVE � NIA: 4011903 07/01/2017 07/01/2018 £ L EACH ACC(DEfiIT S 1,000,000 _ __. — OFFICEPJMEMBEREXCLUDED? (Mandatory in NH) E.L. DISEASE - EA EMPLOYEE, $ 1,000,000 If yes- describe under DESCRIPTION OF OPERATIONS beio,N - E.L. DISEASE - POLICY LIMIT ' $ 1,000,000 i j f DESCRIPTION OF OPERATIONS I LOCATIONS t VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) Unless otherwise stated in the policy provisions, coverage is in Colorado only. Refer to the Acord 101 Additional Remarks Schedule for supplemental cancellation notification information. Excluded (If any) : Judy Dorsey, Daniel Epstein, Judy Dorsey, Treasury Stock CERTIFICATE HOLDER CANCELLATION 1815638 City of Fort Collins Attn: Isaac Medina Environmental Planner PO Box 580 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 Pinnacol Assurance ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD CERTIFICATE HOLDER COPY IMPORTANT If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). 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). DISCLAIMER The Certificate of Insurance on the reverse side of this form does not constitute a contract between the issuing insurer(s), authorized representative or producer, and the certificate holder, nor does it affirmatively or negatively amend, extend or alter the coverage affordedby the policies listed thereon. DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT (CONT) AGENCY CUSTOMER ID: LOC #: N/A N/A ACORD� ADDITIONAL REMARKS SCHEDULE Page 3 of 4 AGENCY Pinnacol Assurance NAMED INSURED The Brendle Group Inc 212 W Mulberry St Fort Collins, CO 80521 POLICY NUMBER 4011903 CARRIER NAIC CODE Pinnacol Assurance 4119UI EFFECTIVE DATE: 07/17/2017 K THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, FORM NUMBER: Acord 25 I2016/0�ORM TITLE: Certificate Of Liability Insurance SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING COMPANY WILL ENDEAVOR TO NOTIFY 10 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO NOTIFY SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE COMPANY, ITS AGENTS OR REPRESENTATIVES. ACORD 101 (2008/01) rJ 2008 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD ACOR" CERTIFICATE OF LIABILITY INSURANCE DATE (MMIDDlYYYY) 07/17/2017 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 poiicy(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 CONTACT NAME: Pinnacol Assurance PHONEFAX ... .... ...................... ....... _ _._............ 7501 E Lowry Blvd A/C No. Ext : (8LC_ No): Denver, CO 80230-7006 E-MAIL ADDRESS: INSURER(S) AFFORDING COVERAGE NAIC # INSURER A: PlnnaC01 Assurance 41190 INSURED INSURER B The Brendle Group Inc��� -- 212 W Mulberry St „(NsuRERC: Fort Collins, CO 80521 INSURER D: _ ................................. 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. .... 1NSR" -._ _...........................................,ADDLSUBR _......_... _.._____ .......................................... ......... POLICY EFF _POLICY EXP.... _ ..............._._........................._............ LTR ( TYPE OF INSURANCE INS V POLICY NUMBER MMIDDIYYYY MMIDDIYYYY LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ ....---r. _....... . _... . :. DAMAGE TO RENTED ......_._............... ..... mm� CLAIMS -MADE v OCCUR PREA7ISES (Ea occurrence ` $ MED EXP (Any one person) i $ PERSONAL 8 ADV INJURY j $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ PRO - POLICY '. ..._. 1ECT LOC PRODUCTS - COMP!OP AGG $ ......... .......... .......... ............. .........-.._....__-___ ._....... _....... OTHER: S AUTOMOBILE LIABILITY - ! COMBINED SINGLE LIMIT $ {Ea accidentl ............ ._....._ .:_... ANY AUTO BODILY INJURY (Per person) S -, OWNED SCHEDULEC _.... _... ____.. ........__.. _ _ __._....... BODILY INJURY (Per accrdent)! $ AUTOS ONLY AUTOS HIRED NON -OWNED PROPERTY DAMAGE is AUTOS ONLY _AUTOS ONLY Per accident) S UMBRELLA LIAR OCCUR EACH OCCURRENCE S - ......_. .. _ ........._... _.._................. _................ EXCESS LIAB �_ CLAIMS MADE AGGREGATE S DED RETENTION S 5 WORKERS COMPENSATION X PER OTH AND EMPLOYERS' LIABILITY Y / N ' STATUTE ,............. ER A AN'1PROPRIETOR,'PARTNErZ'EXECUTIVE E L EACI-1 ACCIDENT $ 1,000,000 OFFICEWMEMBEREXCLUDED? NIA 4011903 07/01/2017 07/01/2018 (Mandatory in NH) E L.'DISEASE EA EMPLOYEE! $ 1,000,000 If yes, describe under --- "DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT :$ 1,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS 1 VEHICLES (ACORD 101, Additional Remarks Schedule. may be attached if more space is required) Unless otherwise stated in the policy provisions, coverage is in Colorado only. Refer to the Acord 101 Additional Remarks Schedule for supplemental cancellation notification information. Excluded (If any) : Judy Dorsey, Daniel Epstein, Judy Dorsey, Treasury Stock CERTIFICATE HOLDER CANCELLATION 1815636 City of Fort Collins PO Box 580 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 PinnacolAssurance O 1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD CERTIFICATE HOLDER COPY IMPORTANT If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). 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). DISCLAIMER The Certificate of Insurance on the reverse side of this form does not constitute a contract between the issuing insurer(s), authorized representative or producer, and the certificate holder, nor does it affirmatively or negatively amend, extend or alter the coverage affordedby the policies listed thereon. DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT (CONT) 'ORi7® AGENCY Pinnacol Assurance POLICY NUMBER 4011903 CARRIER Pinnacol Assurance ADDITIONAL REMARKS AGENCY CUSTOMER ID: N/A LOC #: N/A ADDITIONAL REMARKS SCHEDULE NAMED INSURED The Brendle Group Inc 212 W Mulberry St Fort Collins, CO 80521 NAIC CODE 411901 EFFECTIVE DATE: 07/17/2017 THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, FORM NUMBER: Acord 25 (2016'0OORM TITLE: Certificate of Liability Insurance Page 3 of 4 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING COMPANY WILL ENDEAVOR TO NOTIFY 10 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO NOTIFY SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE COMPANY, ITS AGENTS OR REPRESENTATIVES. ACORD 101 (2008101) © 2008 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD