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HomeMy WebLinkAboutLEWIS TENNIS LLC - INSURANCE CERTIFICATE (10)To: Page 2 of 4 2017-06-05 16:23:06 MDT 18666885709 From: CLC mail •/-,`r..'r A CERTIFICATE OF LIABILITY INSURANCE DATE (MMlDDIYYYY)6/5/2017 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 CL Central NAME: Ewing -Leavitt Insurance Agency, Inc. PHON o t (970) 679-7333 I WCFAX No (866)456-4265 4090 Clydesdale Parkway ADDRESS: Suite 101 INSURERS AFFORDING COVERAGE NAIC # Loveland CO 80538 INSuRERA.Auto Owners 18988 INSURED --- -- INSURER B: Lewis Tennis LLC INSURER C : P O BOX 1207 INSURER D: Laporte CO 80535 1 INSURER F. rnvco Anrc rC'DTICIreTC All lKans=D•1 7/1 R CT. RFVISIONI NIIMRFR' 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 CLAMS. NSR LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER MMLDDIYYYY�, (MMMDIYYYYI LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE S 1,000,000 A GLA1815-t�!ACE X OCCUR DAMAGE 1'O RENTED PREMISES Ea occurrence' S 50,000 MED EXP (Anyone person) S 5,000 X 74667368 7/15/2017 7/15/2018 PERSONAL&ADV INJURY S 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE S 2,000,000 _PRODUCTS - COMPtOP AGO _ $ 2,000,000 X POLICY PRO JECT LOC OTHER. Prop Damage Agg s 2,000,000 AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea accident S 1,000,000 BODILY INJURY (Per person) S A ANY AUTO ALL OWN ED SCHEDULED AUTOS AUTOS NON -OWNED X HIRED AUTOS X AUTOS 74687368 7/15/2017 7/15/2018 BODILY INJURY (Per accident) 5 Or PE TY DAMAGE Pe 5 S UMBRELLA LIAB HCLAIMS-MADE OCCUR EACH OCCURRENCE S AGGREGATE EXCESS LIAR 5 DED I I RETENTIONS WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y / N ANY PROPRIETORiPARTNERiEXECUTIVE PER OTH- STfiT JTE ER E.L. EACH ACCIDENT S OFFICERIMEMBER EXCLUDED? N ! A (Mandatory In NH) E,L. DISEASE ._EA EMPLOYE ---- S ._,____,_,_._____- If yes, describe under DESCRIPTION OF OPERATIONS he!o�i E.L. DISEASE -POLICY LIMIT S DESCRIPTION OF OPERATIONS! LOCATIONS / VEHICLES (ACORD 101. AddlUonal Remarks Schedule, may be attached if more space Is requlred) City of Fort Collins is named as an Additional Insured as per written contract. r COTICIrATr- Wrll r1F0 r'ANr.FI I ATI[)N (970)221-6782 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE City Of Fort Collins THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN PO BOX 580 ACCORDANCE WITH THE POLICY PROVISIONS. Fort Collins, CO 80522 AUTHORIZED REPRESENTATIVE C��..�-!' -111-'-�` �f•:�a=x'=.'z"L__- ' Jacq i zcBrown/JABROW � U 1988-2U14 AL;UKU L;UKtJUKA I IU}N. All rignis reservea. ACORD 25 (2014101) The ACORD name and logo are registered marks of ACORD INS025ooi.w' To: Page 3 of 4 2017-06-05 16:23:06 MDT 18666885709 From: CLC mail ADDITIONAL COVERAGES Ref # Description Hired/borrowed Coverage Code HRDBD Form No. Edition Date Limit f 1,000,000 Limit 2 Limit 3 Deductible Amount Deductible Type Premium Ref # Description Hired/borrowedPhys Dam Coverage Code Form No. Editi on Date Limit 1 1,000,000 Limit 2 Limit 3 Deductible Amount Deductible Type Premium Ref # Description Coverage Code Form No. Edition Date Limit 1 Limit 2 Limit 3 Deductible Amount Deductible Type Premium Ref # Description Coverage Code Form No. Edition Date Limit 1 Limit 2 Limit 3 Deductible Amount Deductible Type Premium Ref # Description Coverage Code Form No. Edition Date Limit f Limit 2 Limit 3 Deductible Amount Deductible Type Premium Ref # Description Coverage Code Form No. Edition Date Limit 1 Limit 2 Limit 3 Deductible Amount Deductible Type Premium Ref # Description Coverage Code Form No. Edition Date Limit 1 Limit 2 Limit 3 Deductible Amount Deductible Type Premium Ref # Description Coverage Code Form No. Edition Date Limit f Limit 2 Limit 3 Deductible Amount Deductible Type Premium Ref # Description Coverage Code Form No. Edition Date Limit 1 Limit 2 Limit 3 Deductible Amount Deductible Type Premium Ref # Description Coverage Code Form No. EDate dition Limit 1 Limit 2 Limit 3 Deductible Amount Deductible Type Premium Ref # Description Coverage Code Form No. Edition Date Limit 1 Limit 2 Limit 3 Deductible Amount Deductible Type Premium OFADTLCV Copyright 2001, AMS Services, Inc. To: Page 4 of 4 2017-06-05 16:23:06 MDT 18666885709 From: CLC mail Agency Code 32-0043-00 Policy Number 044632-74687368 COMMERCIAL GENERAL LIABILITY 55170 (12-04) THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - STATE OR POLITICAL SUBDIVISIONS - PERMITS RELATING TO PREMISES This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART. SCHEDULE State or Political Subdivision: CITY OF FORT COLLINS (If no entry appears above, information required to complete this endorsement will be shown in the Declarations as applicable to this endorsement.) A. SECTION II - WHO IS AN INSURED is amended to 2. The construction, erection, or removal of eleva- include as an additional insured any state or politi- tors; or cal subdivision shown in the Schedule, subject to the following additional provision: 3. The ownership, maintenance, or use of any elevators covered by this insurance. This insurance applies only with respect to the fol- lowing hazards for which the state or political sub- division has issued a permit in connection with premises you own, rent, or control and to which this insurance applies: 1. The existence, maintenance, repair, construc- tion, erection, or removal of advertising signs, awnings, canopies, cellar entrances, coal holes, driveways, manholes, marquees, hoistaway openings. sidewalk vaults, street banners, or decorations and similar exposures: or B. Under SECTION III - LIMITS OF INSURANCE, the following is added: The limits of liability for the additional insured are those specified in the written contract or agreement between the insured and the state or political sub- division, not to exceed the limits provided in this policy. These limits are inclusive of and not in addition to the limits of insurance shown in the Declarations. Includes copyrighted material of Insurance Services Office, Inc., with its permission. 55170 (12-04) Copyright, Insurance Services Office, Inc., 1984, 2003. Page 1 of 1