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HomeMy WebLinkAbout563034 MEDORA CORPORATION - INSURANCE CERTIFICATE (5)MEDOR-1 OP ID: PK ACORO CERTIFICATE OF LIABILITY INSURANCE M/D (MDlYY YY) 1DAT016 E (M / D/YY 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 Dacotah Ins - Dickinson PO Box 1037 Dickinson, ND 58602-1037 CONTACT Thomas Heisler NAME: PHONE FAX /C No Ext : 701-225-1200 A/C,No): 701-483-0102 A/C, ADDRESS: Tom.heisler@dactoahbank.com Thomas Heisler INSURERS AFFORDING COVERAGE NAIC # INSURER A: Travelers Indemnity Company 25666 INSURED Medora Corporation, Medora Environmental Inc, Medora Tran -sport Corp, Gladdin LLC, PSI- INSURER B INSURER C : INSURER D ETS LLC, Solarbee Export Corp Joel Bleth 3225 HWY 22 N INSURER E : INSURER F : Dickinson ND 58601 COVERAGES CERTIFICATE NUMBER: 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 SUB WV POLICY NUMBER MMLPOLDD ICY EFF YYYY POLICY EXP MM DD YYYY LIMITS A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,00 CLAIMS -MADE a OCCUR X X Y6600E550663COF17 01/01/2017 01/01/2018 DAMAGETORENTED PREMISES Ea occurrence 1,000,00( $ r MED EXP (Any one person) $ 5,00 PERSONAL & ADV INJURY $ 1,000,00 GEN'L AGGREGATE LIMIT APPLIES PER. GENERAL AGGREGATE $ 2,000,00 PRODUCTS - COMP/OP AGG $ 2,000,00 POLICY PE� LOC E&O $ 1,000,00 OTHER: AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea accident $ 1,000,00 BODILY INJURY (Per person) $ A X grvvnuro X X BAOE55066317CAG 01/01/2017 01/01/2018 BODILY INJURY (Per accident) $ ALL OWNED SCHEDULED AUTOS AUTOS NON -OWNED HIRED AUTOS AUTOS PROPERTY DAMAGE Per accident $ $ X UMBRELLA LAB OCCUR EACH OCCURRENCE $ 5,000,00 HCLAIMS-MADE AGGREGATE $ 5,000,00 A EXCESS LIAR X X YSMCUPOE550663TIL17 01/01/2017 01/01/2018 DED I I RETENTION $ 0 $ A WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE Y OFFICER/MEMBER EXCLUDED? (Mandatory in NH) N/A X YHUB0E51928A17 01/01/2017 01/01/2018 PER OTH- STATUTE X ER E.L. EACH ACCIDENT $ 1,000,00 E L. DISEASE - EA EMPLOYEE $ 1,000,00 j EL. DISEASE - POLICY OMIT $ 1,000,00 If yes, describe under DESCRIPTION OF OPERATIONS below A Foreign Liab ZPP15R9678317GC 01/01/2017 01/01/2018 GL & Auto 1,000,00 A Mfg E&O ZPL91M249231743 01/01/2017 01/01/2018 Mfg E&O 1,000,00 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) Primary Additional Insured & 30 Day Cancellation Endorsements are added for the City of Fort Collins on the General, Auto Liability policies. rFRTIFIrGTF Hnl nFR CANCELLATION CITYFOR SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. City of Fort Collins PO Box 580 Fort Collins, CO 80522 AUTHORIZED REPRESENTATIVE ACORD 25 (2014/01) © 1988-2014 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD