HomeMy WebLinkAboutJIM BLACK CONSTRUCTION INC - INSURANCE CERTIFICATE (7)DATE (MM/D DIYYYY)
ACOR" CERTIFICATE OF LIABILITY INSURANCE 9/29/2017
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 endorsement(s).
PRODUCER CONTACT
NAME:
a/coNN .Ext): (661)266-9390 1
AIC No: (661)266-9391
Driscoll & Driscoll Insurance Agency, Inc. ADUResS:certsllIlDriscollandDriscoll.Com
41235 l l th St West, Suite A INSURERS AFFORDING COVERAGE NAIC 0
Palmdale CA 93551 INSURERA:Tokio Marine Specialty Insurance Co
INSURED INSURER B:Philade 1phia Indemnity Insurance Co
INSURER C :
Jim Black Construction, Inc. INSURERD:
12279 Pennsylvania St INSURERE: _
Thornton CO 80241 INSURERF:
C(IVFRAr;FR CFRTIFIrATF NIIMRFR•CL1792902858 RFVISION NUMRFR-
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 ADDL SUER POLICY EFF POLICY EXP LIMITS
LTR TYPE OF INSURANCE POLICY NUMBER MM/DDNYYY MM/DD/YYYY
X
COMMERCIAL GENERAL LIABILITY
EACH OCCURRENCE
$ 1,000,000
A
CLAIMS -MADE OCCUR
DAMAGE TO
PREMISESE.Eoccurrence)
$ 100,000
MED EXP (Any one person)
$ 5,000
PPKI720334
10/1/2017
10/1/2018
PERSONAL 8 ADV INJURY
$ 1,000,000
GENERAL AGGREGATE
$ 2,000,000
AGGREGATE LIMIT APPLIES PER:
�GEN'L
X
^I
POLICY ❑ PRO JECT ❑ LOC
PRODUCTS -COMP/OP AGG
$ 2,000,000
$
OTHER:
AUTOMOBILE LIABILITY
COMBINED SINGLE LIMIT
Ea accident)
$ 11000,000
BODILY INJURY (Per person)
$
B ANY AUTO
X'ALL OWNED SCHEDULED
AUTOS AUTOS
PHPK1720349
10/1/2017
10/1/2018
BODILY INJURY (Per accident)
$
PROPERTY DAMAGE
Per accident
$
NON -OWNED
X HIRED AUTOS X AUTOS
Bus Auto Enhncmt Endt
$
UMBRELLA LIAB
X
OCCUR
EACH OCCURRENCE
$ 4,000,000
AGGREGATE
$ 4,000,000
A
X
EXCESS LIAB
CLAIMS -MADE
DED RETENTION$
$
PUB602531
10/1/2017
10/1/2018
WORKERS COMPENSATION
AND EMPLOYERS' LIABILITY YIN
ANY PROPRIETOR/PARTNER/EXECUTIVE
PER OTH-
STATUTE ER
E.L. EACH ACCIDENT
$
OFFICER/MEMBER EXCLUDED? ❑
N / A
-- -- -
(Mandatory in NH)
E.L. DISEASE - EA EMPLOYE
$
E.L. DISEASE - POLICY LIMIT
If yes. describe under
DESCRIPTION OF OPERATIONS below
$
A
Contr Pollution Liability
PPK1720356 10/1/2017 10/1/2018
Per Occ/Agg 1 M / 2 M
A
Professional Liability
PPK1720356 10/1/2017 10/1/2018
Claims Made 1,000,000
DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required)
** For Informational Purposes Only**
L;tK I It-IL;A I t MULUtK l HIV I,CLLH I IUIV
City of Fort Collins
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
ss Driscoll, Sr/DMA
(J 1988-2014 ACORD CORPORATION. All rights reserved.
ACORD 25 (2014/01) The ACORD name and logo are registered marks of ACORD
INS025 (201401)