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HomeMy WebLinkAboutSURE SHOT DRILLING LLC - INSURANCE CERTIFICATE (2)® ACORN CERTIFICATE OF LIABILITY INSURANCE `.../ DATE (MM/DD/YYYY) 2/28/2018 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 Olson & Olson Ltd 5655 S Yosemite Street #200 Greenwood Village CO 80111 CONTACT NAME: PHONE FAX A/c xt : 303-867-2055 A/c No): 303-867-2074 AIL aoDRESS: o2@olsonandolson.com INSURERS AFFORDING COVERAGE NAIC # INSURER A: Charter Oak Fire Ins Co 25615 INSURED SURES-2 INSURER B: Travelers Prop Cas Co of Amer 25674 Sure Shot Drilling, LLC Sure Shot Holdings, LLC INsuRERc: Farmington Casualty Company 41483 695 S Colorado Blvd. #440 INSURERD: INSURER E : Denver CO 80220 INSURER F : CnVFRAl CFRTIFICATF NUMRER' 1611941713 REVISION NUMBER: 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 WV POLICY NUMBER POLICY EFF MM/DD/YYYY POLICY EXP MM/DD/YYYY LIMITS A GENERAL LIABILITY X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE L X_I OCCUR DTC05F464179COF18 3/2/2018 3/1/2019 EACH OCCURRENCE $ 1,000,000 DAMAGE TO RENTED PREMISES Ea occurrence $ 300,000 $ 10,000 _ $1,000,000 MED EXP (Any one person) PERSONAL & ADV INJURY GENERAL AGGREGATE $2,000,000 GENT AGGREGATE LIMIT APPLIES PER: POLICY X PRO- LOC PRODUCTS - COMP/OP AGG $ 2,000,000 $ B AUTOMOBILE LIABILITY X ANY AUTO ALL OWNED SCHEDULED X AUTOS AUTOS X NON -OWNED HIRED AUTOS AUTOS DT8105F464179TIL18 3/2/2018 3/1/2019 COMBINED SINGLE LIMIT Ea $1,000,000 BODILY INJURY (Per person) _ $ BODILY INJURY (Per accident) $ PROP RTY DAMAGE $ B X UMBRELLA LIAB EXCESS LIAB X OCCUR CLAIMS -MADE CUP2J2113911826 3/2/2018 3/1/2019 EACH OCCURRENCE $ 4,000,000 AGGREGATE $ DED X RETENTION $ 10,000 $ C WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y / N ANY PROPRIETOR/PARTNER/EXECUTIVE ❑ OFFICER/MEMBER EXCLUDED? (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below N/A DTFUBSG78986618 3/1/2018 3/1/2019 X WC STATU- OTH- E.L. EACH ACCIDENT $1,000,ODD E.L. DISEASE - EA EMPLOYEE $1,000,000 E.L. DISEASE - POLICY LIMIT $ 1,000,000 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required) Certificate Holder and those listed below (if any) are Additional Insureds as respects General Liability and Umbrella Liability on a Primary and Non -Contributory basis, and Auto Liability only if required by written contract or agreement and coverage applies only as respects work performed by the Insured for the Additional Insureds. All coverage terms, conditions, and exclusions of the policy apply. The Worker's Compensation, General Liability, Auto Liability, and Umbrella Liability policies include a Waiver of Subrogation in favor of the Additional Insureds only if required by written contract or agreement. Contractor's License. CFRTIFIrATF LIr11 r1FR CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. City of Ft Collins PO Box 580 Fort Collins CO 80522-0580 AUTHORIZED REPRESENTATIVE © 1988-2010 AGORD GOKPOKA I FUN. An rlgnts reservea. ACORD 25 (2010/05) The ACORD name and logo are registered marks of ACORD