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HomeMy WebLinkAboutBLACK TIMBER BUILDERS LLC - INSURANCE CERTIFICATE (10)BLACK-3 OP ID: PB ACORO CERTIFICATE OF LIABILITY INSURANCE DATE Y 07 7I111017 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 Paula Blohm _ Madison Insurance Group NAMEPHONE 30la Blom - FAX 600 S. Cherry Street, #900 LA/c, No.,,): (A/C No): 303-322-0874 Denver, Ja say ADDRESS: pblohm@madisoninsurance.net Sharma Jamsay INSURERS AFFORDING COVERAGE NAIC # INSURER A:Pinnacol Assurance Company 41190 INSURED Black Timber Builders, LLC INSURER B : Colony Insurance Company 39993 Kyle Meyer INSURER C : 219 E. Elizabeth St. Fort Collins, CO 80524 INSURERD: INSURER E : INSURER F : RC1VFFtof:F� CFI?TICICGTC ti:IAARCL- OM1101 la, wr„aaoco. 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. IN -SR - -- _ ADDLTSUBR _ POLICY EFF POLICY EXP LTR TYPE OF INSURANCE VIVID POLICY NUMBER MM/DD/YYYY) (MM/DD1YYYYJ LIMITS B X COMMERCIAL GENERAL LIABILITY EACH RRENCE $ 1,000,00 CLAIMS-MADE I X I OCCUR 103 GLOO14825-00 07/12/2017 07/12/2018 DAMXOCCU PREMISES Ea occurrence $ 100,00 MED EXP (Any one person) $ 5,00 PERSONAL & ADV INJURY $ 1,000,00 GEN'L AGGREGATE LIMIT APPLIES PER: POLICY PRO- JECT LOC GENERAL AGGREGATE $ 2,000,00 PRODUCTS -COMP/OPAGG $ 2,000,00 $ OTHER: AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea accident $ BODILY INJURY (Per person) _ $ ANY AUTO NOT WITH MADISON ALL OWNED SCHEDULED AUTOS AUTOS tid BODILY INJURY Per accident) ( ) $ HIRED AUTOS NON -OWNED AUTOS PROPERTY DAMAGE Per accident $ $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ AGGREGATE EXCESS LIAB CLAIMS -MADE $ DED RETENTION $ $ A WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y / N ! ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICERIMEMBER EXCLUDED'? � N / A 190143 03/01/2017 03/01/2018 PER OH - X STATUTE ER' E.L. EACH ACCIDENT $ 100,00 E.L. DISEASE - EA EMPLOYEE $ 100,00 (Mandatory in NH) Ifes dascr be ender DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT $ 500,00 DESCRIPTION OF OPERATIONS I LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) an-t.921. k"_\■--§GPJ 01NJ.4GI CITFTC2 The City of Fort Collins P.O. 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 qu'-J� bw� © 1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25 (2014/01) The ACORD name and logo are registered marks of ACORD