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HomeMy WebLinkAboutLA WOODWORKS INC - INSURANCE CERTIFICATEACOR" CERTIFICATE OF LIABILITY INSURANCE DATE (MMIDD/YYYY) 1 5/18/2017 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 Karole Peters NAME: PA/ONNo Ex : (970) 679-7355 FAX No: (866)237-2178 Ewing -Leavitt Insurance Agency, Inc. E-MAIL SS:karole-peters@leavitt.com 4090 Clydesdale Parkway INSURERS AFFORDING COVERAGE NAIC # Suite 101 INSURER A ACUITY Group 14184 Loveland CO 80538 INSURED INSURER B :Pinnacol Assurance 41190 INSURER C : LA Woodworks Inc. INSURERD: 4476 Bents Drive INSURER E Windsor CO 80550 INSURER F : COVERAGES CERTIFICATE NUMBER:17-18 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 iNgn SUER wyn POLICY NUMBER O APDDY EFF MMIDPOLICY LIMITS A X COMMERCIAL GENERAL LIABILITY Z46492 6/l/2017 6/1/2018 EACH OCCURRENCE $ 1,000,000 CLAIMS -MADE �X OCCUR DAMAGE TO RENTED PREMISES Ea occurrence) ccurrence $ 500,000 X MED EXP (Any one person) $ 10,000 Blkt Additional Insured X X Blkt Waiver of Subro PERSONAL SADVINJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 POLICY ECT LOC PRODUCTS - COMP/OP AGG $ 2,000,000 $ OTHER: A AUTOMOBILE LIABILITY Z46492 6/1/2017 6/1/2018 COMBINED SINGLE LIMIT Ea accident $ 1,000,000 BODILY INJURY (Per person) $ X ANY AUTO BODILY INJURY (Per accident) $ ALL OWNED SCHEDULED AUTOS AUTOS NON -OWNED X HIRED AUTOS X AUTOS X PROPERTY DAMAGE Per accident $ $ X Blkt AI X Blkt WOS A X UMBRELLA LIAB X OCCUR Z46492 6/1/2017 6/1/2018 EACH OCCURRENCE $ 5,000,000 AGGREGATE $ 5,000,000 EXCESS LIAB CLAIMS -MADE DED I X RETENTION $ 0 $ X B WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE Y� 414 9953. Blanket Waiver of 6/l/2017 6/1/2018 PER - X STATUTE ER E.L. EACH ACCIDENT $ 500,000 OFFICER/MEMBER EXCLUDED? (Mandatory in NH) N/A Subrogation E.L. DISEASE - EA EMPLOYEd $ 500,000 E.L. DISEASE - POLICY LIMIT 1 $ 500,000 If Yes, describe under DESCRIPTION OF OPERATIONS below A Installation Floater Z46492 6/1/2017 6/l/2018 Temporary Storage-$1,000ded $1,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) RE: Block 32 UAB Const Phase. A&P Job # 7106. AP Mountain States LLC, City of Fort Collins, Colorado and others as required by contract are named additional insured on the General Liability and Auto Liability policies as regards work performed by the insured on this project- A waiver of subrogation applies in favor of the additional insureds listed above as regards the General Liability, Auto Liability and Workers' Compensation policies. CERTIFICATE HOLDER L;ANL;tLLAI IUN City of Fort Collins, Colorado PO 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 Karole Peters/KAPETE ACORD 25 (2014/01) INS025 (201401) © 1988-2014 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD