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HomeMy WebLinkAboutTRINET HR III-A INC / L/C/F MASABI LLC - INSURANCE CERTIFICATET3-ON E ,a►coFto® CERTIFICATE OF LIABILITY INSURANCE DATE/YYYY) 6/22/202/2018 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 Commercial Lines - (305) 443-4886 USI Insurance Services National, Inc. CONTNAME: Risk Management Department PHONE FAX tA/c No Ext : 866-443-8489 Arc No : 800-889-0021 E-MAIL ADDRESS: work.comp@trinet.com INSURER(S) AFFORDING COVERAGE NAIC # 2601 South Bayshore Drive, Suite 1600 Coconut Grove, FL 33133 INSURERA: ACE American Insurance Company 22667 INSURED INSURER B : INSURERC: TriNet HR III -A, Inc. INSURERD: L/C/F Masabi LLC INSURER E : 9000 Town Center Parkway INSURER F : Bradenton, FL 34202 COVERAGES CERTIFICATE NUMBER: 13202722 REVISION NUMBER: See below 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'SUBR INS WV POLICY NUMBER POLICY EFF MM/DD/YYYY POLICY EXP MM/DD/YYYY LIMITS COMMERCIAL GENERAL LIABILITY CLAIMS -MADE OCCUR EACH OCCURRENCE $ DAMAGE TO EN PREMISES Ea occurrence S MED EXP (Any one person) $ PERSONAL & ADV INJURY S GEN'L AGGREGATE LIMIT APPLIES PER: POLICY F PRO JECT ❑ LOC OTHER: GENERAL AGGREGATE $ PRODUCTS - COMP/OPAGG $ $ AUTOMOBILE LIABILITY ANY AUTO OWNED SCHEDULED AUTOS ONLY AUTOS HIRED NON -OWNED AUTOS ONLY AUTOS ONLY COMBINED SINGLE LIMIT Ea accident $ BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ PROPERTY DAMAGE Per accident $ UMBRELLALIAB EXCESS LIAB OCCUR EACH OCCURRENCE $ HCLAIMS-MADE AGGREGATE $ DED I I RETENTION $ $ A WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANYPROPRIETOR/PARTNER/EXECUTIVE Y / N OFFICER/MEMBER EXCLUDED? N. (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below NIA WLR C65584815 7/1/2018 7/1/2019 X STATUTE OTH E.L. EACH ACCIDENT 2,000,000 $ E.L DISEASE -EA EMPLOYEE S 2,000,000 E.L. DISEASE - POLICY LIMIT $ 2,000,000 DESCRIPTION OF OPERATIONS / LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) Workers' Compensation coverage is limited to worksite employees of Masabi LLC through a co -employment agreement with TriNet HR III -A, Inc. CLK I IFIGA I t HULULK GAINGtLLA I IUN City of Fort Collins SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 215 N Mason St, PO Box 580 ACCORDANCE WITH THE POLICY PROVISIONS. Fort Collins, CO 80524 AUTHORIZED REPRESENTATIVEQ 14�h'�r""ri+� The ACORD name and logo are registered marks of ACORD @ 1988-2015 ACORD CORPORATION. All rights reserved. ACORD "°°"°° I 1111 1IM $� 111 I11I 1111 11I 111I 1111111111111111111111111111111l .n,_,..,...