HomeMy WebLinkAbout389648 A-1 CHIPSEAL COMPANY - INSURANCE CERTIFICATEA� " CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DD/YYYY)
2/1/2017
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 Deanna Zahn
NAME:
Moody Insurance Agency, Inc. PHA No,E , (303)824-6600 1303)370-oils
8055 East Tufts Avenue ADDRESS: deanna. zahn@moodyins . com
Suite 1000 INSURE S AFFORDING COVERAGE NAIC S
Denver CO 80237 INSURERA:Phoenix Insurance Company 25623
INSURED INSURER B :Travelers Prop Cas CO Of America 25674
A-1 Chipseal Company, DBA: Rocky Mountain Pavement, INSURERC:Pinnacol Assurance 41190
2505 E. 74th Ave INSURERD:Illinois Union Insurance Comnanv 27960
INSURER E : _
Denver CO 80229 INSURER F :
CnVFRAGFS CERTIFICATE NLIMRFR-17-18 w/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. NOT WITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT Wi T H 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 SUBR POLICY NUMBER MOLICY EFF POLICY EXP LIMITS
LTR
X
COMMERCIAL GENERAL LIABILITY
EACH OCCURRENCE
$ 1,000,000
A
CLAIMS -MADE CJ OCCUR
DAMAGE TO RETED
PREMISESEa occurrence
$ 300,000
MED EXP (Any one person)
$ 10,000
X
DTCOOJ73000517PHX
2/1/2017
2/1/2018
PERSONAL & ADV INJURY
$ 1,000,000
GENT AGGREGATE LIMIT APPLIES PER:
GENERAL AGGREGATE
$ 2,000,000
POLICY J I PE� LOC
PRODUCTS -COMP/OP AGG
$ 2,000,000
$
OTHER:
AUTOMOBILE LIABILITY
COEa aMccidentBINED SINGLE LIMIT
$ 1,000,000
BODILY INJURY (Per person)
$
B
X ANY AUTO
ALL OSCHEDULED
AUUTOSS AUTOS
X
DT8100773000517TIL
2/1/2017
2/1/2018
BODILY INJURY (Per accident)
$
PROPERTY DAMAGE
Per accident
$
NON -OWNED
HIRED AUTOS AUTOS
X
UMBRELLA LIAB
X
OCCUR
EACH OCCURRENCE
$ 10,000,000
AGGREGATE
$ 10,000,000
B
EXCESS LIAB
CLAIMS -MADE
DIED I X RETENTION$ 10,000
_
$
CUPOJ8559021726
2/1/2017
2/1/2018
C
WORKERS COMPENSATION
AND EMPLOYERS' LIABILITY Y / N
ANY PROPRIETOR/PARTNER/EXECUTIVE
OFFICER/MEMBER EXCLUDED? �
(Mandatory in NH)
N I A
4055760
2/1/2017
2/1/2018
x I PER
STATUTE ERH
E.L. EACH ACCIDENT
$ 500,000
E.L. DISEASE - EA EMPLOYEE
$ 500,000
E.L. DISEASE - POLICY LIMIT
$ 500,000
If yes, describe under
DESCRIPTION OF OPERATIONS below
D
Pollution Liability
CPYG27165825005
2/1/2017
2/1/2018
Limit peroccurence/aggregate $1,000,000
Retention $25 , 000
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached If more space is required)
City of Fort Collins is listed as additional insured in respect to General Liability and Auto Liability.
rGOTtCIrATI= ur11 ne=0 renlrFl I ATInN
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
City of Fort Collins
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
PO BOX 580
ACCORDANCE WITH THE POLICY PROVISIONS.
Fort Collins, CO 80522
AUTHORIZED REPRESENTATIVE
Deanna Zahn/SANPRO o4..r�i�vr`a� to
U 1988-2014 AGUKU GUKPUKA I IUN. All rlgnts reserves.
ACORD 25 (2014/01) The ACORD name and logo are registered marks of ACORD
INS025 (201401)