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HomeMy WebLinkAboutLA WOODWORKS INC - INSURANCE CERTIFICATE (2)7/18/2017 TE (MM/DD/YYYY) ACCW" CERTIFICATE OF LIABILITY INSURANCE 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: AX Ewing -Leavitt Insurance Agency, Inc. PHONrE Ex (970) 679-7355 FNC No: (866)237-2178 4090 Clydesdale Parkway E-MADDRESS: karole-peters@leavitt.com Suite 101 INSURERS AFFORDING COVERAGE NAIC # Loveland CO 80538 INSURERAACUITY Group 14184 INSURED INSURER B :Pinnacol Assurance 141190 LA Woodworks Inc. INSURER C: 4476 Bents Drive INSURERD: Windsor CO 80550 1 INSURER F : rr)VFRA(.FC rFRTIFIrATF NIIMRFR 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 SUER! POLICY NUMBER POLICY EFF MMIDD/YYYY POLICY EXP MM / D/YYYY LIMITS A X COMMERCIAL GENERAL LIABILITY Z46492 6/1/2017 6/1/2018 EACH OCCURRENCE $ 1,000,000 CLAIMS -MADE � OCCUR DAMAGE TO PREM SES (Ea occurrence) $ 500,000 _7RENTED X MED EXP (Any one person) $ 10,000 Blkt Additional Insured X X Blkt Waiver of Subro PERSONAL BADVINJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 POLICY � JE � U LOC PI 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 X HIRED AUTOS X AUUTOSWNED X PROPER accidentDAMAGE $ $ X Blkt Al X Blkl WOS A X UMBRELLA LIAB X OCCUR Z46492 6/l/2017 6/1/2018 EACH OCCURRENCE $ 5,000,000 AGGREGATE $ 5,000,000 EXCESS LIAB CLAIMS -MADE DED X I RETENTION $ 0 $ X B WORKERS COMPENSATION AND EMPLOYERS' LIABILITY YIN ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? (Mandatory in NH) N I A 4148953 Blanket Waiver of Subrogation 6/l/2017 6/l/2018 X PER OTH- STATUTE ER 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 A Installation Floater Z46492 6/l/2017 6/1/2018 Temporary Storage-$1,000ded $1,000,000 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) RE: Utilities Service Center. Project #: 7157. AP Mountain States LLC, City of Fort Collins 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;ANUtLLAI IUN City of Fort Collins 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 �. ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25 (2014/01) The ACORD name and logo are registered marks of ACORD I NS025 (201401)