HomeMy WebLinkAboutNORTH FORK NATIVE PLANTS - INSURANCE CERTIFICATE (2)AC"R" 0
CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DDMlYI)
�_' 3/15/2018
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: ANDERSON MATT
Western Community Ins Co arch o E 208— 4-2 ac No: 208-232-3608
PO Box 4848 EMAIL commcerts@idfbins.com
ADDRESS:
Pocatello, ID 83205-4848 INSURER(S) AFFORDING COVERAGE NAIC #
INSURER A: Western Community Ins Co 39519
INSURED INSURER B :
IIIIIIIIII11I11IIIIIIIII IIIIIIIIIIIIIIIIIIIII IIII�II INSURER C:
NORTH FORK NATIVE PLANTS INC
% JEFF KLAUSMANN & TIM WATERS INSURERD:
PO BOX 1 115INSURERE:
DR I GGS ID 83422 INSURER F:
rnvcoer_cr rPDTIFIreTI= NI IMRI=R• RFVISION NUMBER: AF0418
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 ADDL S POLICY NUMBER MM DEFF DPOUC MM`
LTR DDIYYYYI LIMITS
GENERAL LIABILITY
EACH OCCURRENCE
$ 1,000,000
COMMERCIAL GENERAL
DAMAGE To READ
PREMISES Ea occurrence
$ 100,000
MED EXP (Any one person)
$ 5,000
_LIABILITY
l
CLAIMS -MADE OCCUR
PERSONAL & ADV INJURY
$ 1,000,000
A
Y
Y
868929o4
4/10/18
4/10/19
GENERAL AGGREGATE
$ 2,000,000
GEN'L AGGREGATE LIMIT APPLIES PER:
PRODUCTS - COMP/OP AGG
$ 2,000,000
$
POLICY PRO- LOC
AUTOMOBILE LIABILITY
COMBINED SINGLE L M T
Ea accident
$ 1,000,000
BODILY INJURY (Per person)
$
ANY AUTO
BODILY INJURY (Per accident)
$
A
ALL OWNED SCHEDULED
AUTOS NAUTOS ON OWNED
X HIRED AUTOS X AUTOS
Y
Y
86892904
4/ 10/ 18
4/ 10/ 19
PROPERTY DAMAGE
Per accident)$
$
UMBRELLA LIAB
OCCUR
EACH OCCURRENCE
$
HCLAIMS-MADE
AGGREGATE
$
EXCESS LIAR
DED I I RETENTION $
$
WORKERS COMPENSATION
AND EMPLOYERS' LIABILITY YIN
ANY PROPRIETOR/PARTNER'EXECUTIVE
WC STATU- OTH-
TORY LIMIIS
EE.L.EACH ACCIDENT
$
E.L. DISEASE - EA EMPLOYEE
$
OFFICER/MEMBER EXCLUDED? ❑
(Mandatory in NH)
N I A
E.L DISEASE - POLICY LIMIT
$
If yes, describe under
DESCRIPTION OF OPERATIONS below
DESCRIPTION OF OPERATIONS / LOCATIONS I VEHICLES (Attach ACORD 101, Additional Remarks Schedule, If more space is required)
ncnrl ran •Tc uru nco rANrFI I ATI171N
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
t I I I I I
I I I I I I I I I I I I I I I I I I I I I I I I I I t I I I t I t 11I I l 111 1 1 1
ACCORDANCE WITH THE POLICY PROVISIONS.
CITY
OF FORT COLLINS
AUTHORIZED REPRESENTATIVE �7
215 N MASON ST FL 2
FORT
COLLINS CO 80524
ACORD 25 (2010/05) U T 956-tUT U AevrcU L L/KrUKA I IUIv. An ngnis reserveu.
The ACORD name and logo are registered marks of ACORD
AGENCY CUSTOMER ID:
LOC #:
,4 C ADDITIONAL REMARKS SCHEDULE
Page of
AGENCY
Western Community Ins Co
NAMED INSURED
NORTH FORK NATIVE PLANTS INC
% JEFF KLAUSMANN & TIM WATERS
PO Box 1115
DR I GGS I D 8 422
POLICY NUMBER
868 2 o4
CARRIER
NAIC CODE
EFFECTIVE DATE:
AnnITIONAL REMARKS
THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM,
FORM NUMBER: FORM TITLE:
CITY OF FORT COLLINS
is listed as an additional insured per endorsements
CG 20 15 0 1 /88) I DCA 389 (01 /04)
Waiver of subrogation applies per endorsement CG 24 04 0 0/93)
Waiver of subrogation applies per endorsement CA 04 44(03/10)
ACORD 101 (2008101) V zuus ACUKU L;UKFUKAI IUN. Au ngnis reservea.
The ACORD name and logo are registered marks of ACORD