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HomeMy WebLinkAbout608057 GOLD STAR CONCRETE INC - INSURANCE CERTIFICATE (9)A� �® DATE (MM/DD/YYYY) �.. CERTIFICATE OF LIABILITY INSURANCE F5/412018 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: It 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 UUNIAUI NAME; Scott Anderson Commercial Risk Solutions PHONE — FAX -- 6600 E Hampden Ave Ste 200 lAIC. No. o at): 303-996-7801 A/C No): 303-757-7719 Denver CO 80224 E-MAIL , sanderson@crsdenver.com INSURERIS) AFFORDING COVERAGE NAIC N INSURED GOLST-2 INSURERB: Pinnacol Assurance 41190 Gold Star Concrete, Inc. 119 Muriel Dr. INSURERC: Northglenn CO 80233 INSURER D : 1 I INSURER F : COVFRAGFS CFRTIFICATF NIIMRFR• r77FA'1A01 RFVICIr1N tU111UIRFR• 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 L OF INSURANCE ADDTYPE L' POLICY NUMBER POLICY EFF MM/DD/YYY POLICY EXP M D/YYYY I LIMITS A X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE I - I OCCUR Y Y 5X86615 5/6/2016 5/6/2019 EACH OCCURRENCE $1,000,000 DAMAGE TO RENTED PREMISES IEa occurrence $ 500,000 MED EXP (Any oneperson) $ 10,000 PERSONAL 8 ADV INJURY $1,000,000 GENT AGGREGATE LIMIT APPLIES PER: POLICY PRO ❑ LOC JECT OTHER: GENERAL AGGREGATE $ Z000,000 PRODUCTS - GOMP.rOP AGG _ $ 2.000,000 $ A AUTOMOBILE LIABILITY ANY AUTO OWNED SCHEDULED AUTOS ONLY AUTOS HIRED X NON -OWNED AUTOS ONLY AUTOS ONLY Y SX86615 sffim1B 5160119 COEaMBI accidd' nt-,13 GLE LIMIT en $ 1.000,000 X BODILY INJURY (Per person) $ BODILY INJURY (Per accident) ) $ X PROPERTY DAMAGE Per ecacdent3 $ A X UMBRELLA LIAB EXCESS LIAB X OCCUR CLAIMS -MADE 5X86615 5/6/2018 5/6/2019 EACH OCCURRENCE $4,000,000 AGGREGATE $ L000,000 DED RETENTION $ B WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y / N ANYPROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? (Mandatory In NH) IT yes, describe under DESCRIPTION OF OPERATIONS below NIA 4187477 111IJ2017 11/1/2018 X STATUTE PER OTH ER �— __ -----_.--- E.L. EACH ACCIDENT $ 500.000 E.L. DISEASE - EA EMPLOYEE — $ 500.000 E.L. DISEASE - POLICY LIMIT $ 500 000 I DESCRIPTION OF OPERATIONS / LOCATIONS) VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space Is required) Certificate holder is included as additional insured on the General Liability with respect to ongoing and completed operations of the named insured for the certificate holder as required by written contract. All policy terms, conditions and exclusions apply. La13a�1�7C7_\I�:U�slsla: City of Fort Collins Purchasing Department 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 /A-dj4-kk © 1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD