HomeMy WebLinkAbout111775 KUBAT EQUIPMENT AND SERVICES CO - INSURANCE CERTIFICATE7ATE (MM/DDNYYY)
A� " CERTIFICATE OF LIABILITY INSURANCE
1/21/2017
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 endorsements .
PRODUCER CONTACT Leigh Pullen
NAME: g
Moody Insurance Agency, Inc. PHONE (303) 824-6600 No: (303)370-0118
8055 East Tufts Avenue ADDRESS:leigh.pullen@moodyins.com
Suite 1000 INSURER(S) AFFORDING COVERAGE NAIC #
Denver CO 80237 _ INSURERA:Homeland Ins Co of NY 34452
INSURED INSURER B :Cincinnati Indemnity Company 23280
Kubat Equipment & Service Company, Inc.(KESCO) INSURERC:Pinnacol Assurance 41190
KESCO Enterprises, LLC INSURERD:
1070 S Galapago St INSURERE:
Denver CO 80223 INSURERF:
rnVFRArZPQ rFRTIFIrATF N1IMRFR•17/18 No Forms 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 TYPE OF INSURANCE ADDL SUER POLICY NUMBER MM/DDPOLICYNYYY MMIO EFF Y EXP LIMITS
LTR
X
COMMERCIAL GENERAL LIABILITY
EACH OCCURRENCE
$ 1,000,000
A
CLAIMS -MADE FX-1 OCCUR
DAMAGE TO RENTED
PREMISES Ea occurrence
$ 150,000
MED EXP (Any one person)
$ 5,000
7930040310002
12/1/2017
12/1/2018
PERSONAL & ADV INJURY
$ 1,000,000
GEN'L AGGREGATE LIMIT APPLIES PER:
GENERAL AGGREGATE
$ 2,000,000
PRODUCTS - COMP/OP AGG
$ 2,000,000
PRO -
POLICY X PRO JECT � LOC
$
OTHER:
AUTOMOBILE LIABILITY
COMBINED SINGLE LIMIT
Ea accident
$ 1,000,000
BODILY INJURY (Per person)
$
B
X ANY AUTO
ALL OWNED SCHEDULED
AUTOS AUTOS
NON -OWNED
HIRED AUTOS AUTOS
EBA0219301
12/1/2017
12/1/2018
BODILY INJURY (Per accident)
$
-
PROPERTY DAMAGE
Per accident
$
X
UMBRELLA LIAB
X
OCCUR
EACH OCCURRENCE
$ 5,000,000
AGGREGATE
$ 5,000,000
A
EXCESS LIAB_
CLAIMS -MADE
DIED I X I RETENTION$ 0
$
7930040320002
12/1/2017
12/1/2018
C
WORKERS COMPENSATION
AND EMPLOYERS' LIABILITY
ANY PROPRIETOR/PARTNER/EXECUTIVE Y�
OFFICER/MEMBER H) EXCLUDED?
(Mandatory in NH)
A
NIA
4119184
12/1/2017
12/1/2018
X PER OETH-
STATUTE ER
E.L. EACH ACCIDENT
.
$ 1,000,000
�',E.L. DISEASE - EA EMPLOYE
E. .
$ 1,000,000
E.L. DISEASE - POLICY LIMIT
$ 1,000,000
If yes, describe under
DESCRIPTION OF OPERATIONS below
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required)
CERTIFICATE HOLDER L;ANL;tLLA I IUN
City of Fort Collins
330 South College Avenue
P.O. Box 580
Fort Collins, CO 80522-0580
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
Leigh Pullen/LEIPUL
U 1938-2014 ACORD CORPORATION. All rights reserves.
ACORD 25 (2014/01) The ACORD name and logo are registered marks of ACORD
INS025 (201401)