HomeMy WebLinkAbout389648 A-1 CHIPSEAL COMPANY - INSURANCE CERTIFICATE (15)DATE (MM/DD/YYYY)
AC oRo® CERTIFICATE OF LIABILITY INSURANCE
4/30/2018
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 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: Deanna Zahn, ACSR
Moody Insurance Agency, Inc. . (303) 824-6600 F No: (303)370-0118
PNONE
BOSS East Tufts Avenue AIL
ADDRESS:deanna.zahnomoodyins.com
Suite 1000 INSURE 8 AFFORDING COVERAGE NAIL#
Denver CO 80237 INSURERA:Phoenix Insurance Company 25623
INSURED INSURERB:Travelers Prop C'as CO of America 25674
A-1 Chipseal Company, DBA: Rocky Mountain Pavement, INSURERC:Pinnacol Assurance 41190
2505 E. 74th Ave INSURERD:Illinois Union Insurance Company 27960
INSURERE:AGCS Marine Ins Co 22837_
Denver CO 80229 INSURERF:
rnvcoAccc CCRTWICATG NIIMRFR•18-19 w/froms RFVISInN 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 TYPE OF INSURANCE DDL iv POLICY NUMBER MMIDCD/YYYY MM Y EFF PODDYYYYY
L I LIMITS
X
COMMERCIAL GENERAL LIABILITY
EACH OCCURRENCE
$ 11000,000
A
CLAIMS -MADE Fx_1 OCCUR
DTCOOJ30005PHXIB
$ 300,000
PREMISES Ea occurrence
MED EXP (Any one person)
X
Additional Insured Status 2/1/2018
2/1/2019
$ 10,000
Applies Only To The Extent
$ 11000,000
PERSONAL & ADV INJURY
GEN'LAGGREGATE LIMIT APPLIES PER:
Provided in Forms
GENERAL AGGREGATE
$ 2,000,000
PRODUCTS -COMP/OPAGG
$ 2,000,000
POLICY a JEa LOC
CG D3 16 11/11 &
$
OTHER:
CG D2 46 08/05
AUTOMOBILE LIABILITY
EaMa�dent ED SINGLE LIMIT$
11000,000
BODILY INJURY (Per person)
$
B
IANY AUTO
AU OS SCHEDULEDAUTOS
AUTOS NON -OWNED
HIREDAUTOS X AUTOS
XDT810OJ30005TILIB
2/1/2018
2/1/2019
BODILYINJURY(Peraccident)
$
PROPERTY DAMAGE
Per accident
$
Co rehesive/Collision Ded.
$ 21000
X
UMBRELLA LIAB
X
OCCUR
EACH OCCURRENCE
$ 10,000,000
AGGREGATE
$ 10, 000, 000
B
EXCESS UAS
CLAIMS -MADE
DED X RETENTION$ 10,000
$
CUP2J3100431826
2/1/2018
2/l/2019
C
WORKERS COMPENSATION
AND EMPLOYERS' LIABILITY
ANY PROPRIETOR/PARTNER/EXECUTIVE —]
OFFICER/ME BER EXCLUDED?
(Mandatory In NH)
NIA
4055760
2/1/2018
2/1/2019
X PERSTATUTE ER
—'
E.L. EACH ACCIDENT
$ 500,000
E.L. DISEASE - EA EMPLOYEA
$ 500,000
E.L. DISEASE - POLICY LIMIT
1 $ 500,000
If yes, describe under
DESCRIPTION OF OPERATIONS below
I
D
Pollution Liability
CPYG27165825006 2/l/201a
2/1/2019
Umttperoccurence/aggregate 51000,000
E
Motor Truck Cargo
IMZI93038733 2/1/2018
2/l/2019
Limit. 100,000
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached If more space is required)
Re: 8522 Asphalt Surface Treatment Project - 2018 Renewal
City of Fort Collins and their officers, agents, and employees are included as additional insured with
respect to General and Autmobile Liability as required by written contract.
ULKI II-IUA It HULUtK l A1V l.CLLN 1 IVIY
City of Fort Collins
300 Laporte Avenue
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
Zahn, ACSR/DANFLI 16�1 '� e
U 19BB-2014 AUUKU UUKVUKA I IUN. All rignts reserve0.
ACORD 25 (2014/01) The ACORD name and logo are registered marks of ACORD
INS025 (201401)