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HomeMy WebLinkAboutLAKESIDE MECHANICAL SERVICE INC - INSURANCE CERTIFICATE (12)A� " CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DD/YYYY) 2/17/2017 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 role Peters NAME: Ewing —Leavitt Insurance Agency, Inc. AO No (970) 679-7333 -4265 /E ac No: (8 66) 45 6 4090 Clydesdale Parkway ADDRESS:karole-peters@leavitt.com Suite 101 INSURERS AFFORDING COVERAGE NAIC # Loveland CO 80538 INSURERA:Secura Insurance 22543 INSURED INSURERB:Pinnacol Assurance 41190 Lakeside Mechanical Service, Inc. INSURERC: 1008 Engleman Place INSURERD: INSURER E Loveland CO 80538 INSURER F cnVFRAt;Fs CFRTIFICATF NUMBFR-17-18 Pcka 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 IMMIDDfYYYYJ MM DD/YYYY LIMITS A X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE � OCCUR Blkt Additional Insured TC3189005 2/23/2017 2/23/2018 EACH OCCURRENCE $ 1,000,000 PREM SESOEa oNcurrDence $ 500,000 X MEO EXP (Any one person) $ 5,000 X Blkt Waiver of Subro PERSONAL & ADV INJURY $ Included GEN'L AGGREGATE LIMIT APPLIES PER: POLICY F JE� 17 LOC OTHER: GENERAL AGGREGATE $ 2,000,000 PRODUCTS - COMP/OP AGG $ 2,000,000 $ A AUTOMOBILE LIABILITY X ANY AUTO ALL OWNED SCHEDULED AUTOS AUTOS NON -OWNED X HIRED AUTOS X AUTOS A3189006 2/23/2017 2/23/2018 COMBINED SINGLE LIMIT Ea accident $ 1,000,000 BODILY INJURY (Per person) $ $ BODILY INJURY (Per accident) PROPERTY DAMAGE Per accident $ A X UMBRELLA LIAB X OCCUR EXCESS LIAB CLAIMS -MADE CU3189007 2/23/2017 2/23/2018 EACH OCCURRENCE $ 5,000,000 $ 5,000,000 AGGREGATE DIED X RETENTION $ 10 000 $ B WORKERS COMPENSATION AND EMPLOYERS' LIABILITY YIN ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICERIMEMBER EXCLUDED? (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below N / A 4104726 Blanket Waiver of Subrogation 5/1/2016 5/1/2017 X TH STATUTE ER E.L. EACH ACCIDENT $ 500,000 E.L. DISEASE - EA EMPLOYEE $ 500,000 E.L. DISEASE - POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) GERIIFIGAIE HULULK GANL r-LLAIILIN 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 role Peters/KAPETE © 1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25 (2014/01) The ACORD name and logo are registered marks of ACORD INS025 (201401)