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®
AC R" CERTIFICATE OF LIABILITY INSURANCE
DATE (MM/DDIYYYY)
10/31/2017
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 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
CONTACT
NAME:
PHONE FAX
. 1-877-945-7378 A/C No:1-686-467-2378
Willis of Michigan, Inc.
c/o 26 Century Blvd
P.O. Box 305191
E-MAIL certificates@rillis.com
ADDRESS:
INSURERS AFFORDING COVERAGE
NAIC#
Nashville, TN 372305191 USA
INSURERA: StarNet Insurance Company
40045
INSURED
INSURERB: Berkley Insurance Company
29580
T2 Systems, Inc.
B900 Keystone Crossing suite 700
INSURERC: Berkley National Insurance Company
38911
INSURER D: AXIS Insurance Company
37273
Indianapolis, IN 46240
INSURER E :
INSURER F :
COVERAGES CERTIFICATE NUMBER: W4234431 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
SR
TYPE OF INSURANCE
ADDL
SUBR
--
POLICY NUMBER
POLICYW EFF
MMIDD/YY
POLICY EXP
MMIDD/YYYY
LIMITS
X
COMMERCIAL GENERALLIABILITY
EACH OCCURRENCE
$ 1,000,000
CLAIMS -MADE FX I OCCUR
DAMAGE To RENTED
PREM SES Ea ocrurrrrence
$ 1,000,000
MED EXP (Any one person)
$ 10,000
A
Y
TCP 7007311-12
10/31/2017
10/31/2018
PERSONAL & ADV INJURY
$ 1,000,000
GEN'L AGGREGATE LIMIT APPLIES PER:
GENERAL AGGREGATE
$ 2,000,000
PRODUCTS-COMP/OP AGG
$ 2,000,000
X PRO -
POLICY PRO JECT ElLOC
$
OTHER:
AUTOMOBILE LIABILITY
COMBINED SINGLE LIMIT
Ea accident
$ 1,000,000
BODILY INJURY (Per person)
$
X ANY AUTO
A
OWNED SCHEDULED
AUTOS ONLY AUTOS
y
TCP 7007311-12
10/31/2017
10/31/2018
BODILY INJURY (Per acadent)
$
HIRED NON -OWNED
AUTOS ONLY AUTOS ONLY
PROPERTY DAMAGE
Per accident
$
B
X
UMBRELLALIAB
EXCESS LIAB
X
OCCUR
CLAIMS -MADE
TUL 7007372
10/31/2017
10/31/2018
EACH OCCURRENCE
$ _10,000,000
AGGREGATE
$ 10,000,000
DED I X I RETENTION$ 10,000
$
rC
WORKERS COMPENSATION
AND EMPLOYERS' LIABILITY Y / N
ANYPROPRIETOR/PARTNER/EXECUTIVE
OFFICER/MEMBER EXCLUDED?
(Mandatnry in NH)
NIA
TWC 7007313-12
10/31/2017
10/31/2018
X STATUTE ERH
E.L. EACH ACCIDENT
$ 1 , 000 , 000
E.L. DISEASE - EA EMPLOYEE
$ 1,000,000
E.L. DISEASE - POLICY LIMIT
$ 1,000,000
If yes, describe under
DESCRIPTION OF OPERATIONS below
D
Cyber Security Liability/
ECN000249581701
10/31/2017
10/31/2018
Occur./Aggr.
$10,000,000
Professional Liability
Retroactive Date:
1/1/2004
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required)
The City of Fort Collins, CO is added as an Additional Insured as respects the General Liability and Liabilitys.
CERTIFICATE HOLDER CANCELLATION
City of Fort Collins
215 North Mason
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
*k ov V
U 1988-2015 AGURD CURPURA 1 IUN. All rights reserved.
ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD
SR ID: 15262064 BATCH: 497812