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HomeMy WebLinkAbout522800 NORTH FORK NATIVE PLANTS - INSURANCE CERTIFICATEAC CERTIFICATE OF LIABILITY INSURANCE DATE MMI��oYYY) 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 NAME: ANDERSON MATT KEY Western Community Ins Co Atc No Ext: 208— 4-2 FUc No: 208-232-3608 PO Box 4848 E-MAIL ADDRESS: commcerts@idfbins.com Pocatello, ID 83205-4848 INSURER(S) AFFORDING COVERAGE NAIC # INSURER A: Western Community Ins Co 39519 INSURED INSURER B : INSURERC: NORTH FORK NATIVE PLANTS INC % JEF F KLAUSMANN & TIM WATERS INSURERD: PO BOX 1115 INSURERE: DRIGGS ID 83422 INSURERE: rnvFRArFC r.FRTIFIrATF NIIMRFR- REVISION NUMBER: AF0418 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 OF INSURANCE ADDTYPE INSR WVD POLICY NUMBER MM/DD1YYYY MM DD EXP LIMITS A GENERAL LIABILITY COMMERCIAL GENERAL LIABILITY CLAIMS -MADE [_)� OCCUR Y Y 86892904 4/ 1 O/ 17 4/ 1 O/ 18 EACH OCCURRENCE $ nn •• DAMAGE TO RENTED PREMISES Ea occurrence $ Q 0 00,000 MED EXP (Any one person) $ 5,000 PERSONAL & ADV INJURY $ GENERAL AGGREGATE $ 2.000,000 GEN'L AGGREGATE LIMIT APPLIES PER: POLICY PR' �' LOC PRODUCTS - COMP/OP AGG $ $ A AUTOMOBILE LIABILITY ANY AUTO ALL OWNED SCHEDULED AUTOS AUTOS NON -OWNED X HIRED AUTOS X AUTOSPeraccident Y N 86892904 4/10/17 4/10/18 COMBINED SINGLE LIMIT Ea_accident $ 909-�000 $ BODILY INJURY (Per person) BODILY INJURY (Per accident) $ - $ PROPERTY DAMAGE UMBRELLA LIAB EXCESS LIAB OCCUR CLAIMS -MADE EACH OCCURRENCE $ _ AGGREGATE $ DED RETENTION $ $ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y / N ANY PROPRIETOR/PARTNER/EXECUTIVE ❑ OFFICER/MEMBER EXCLUDED? (Mandatory in NH) If yes, describe under 1]ESCRIPTJQN OF OPERAAONS-b to NIA WC STATU- OTH- T RYLIMITS E E.L. EACH ACCIDENT $ E.L. DISEASE - EA EMPLOYEE $ DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space Is required) r•c CTIV1f'ATC unt nGo rAmr-m I ATInN SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Ilttltllttttltltttltltlttlilttltlttllltttttltltttlll ACCORDANCE WITH THE POLICY PROVISIONS. CITY OF FORT COLLINS AUTHORIZED REPRESENTATIVE / 215 N MASON ST FL 2 FORT COLLINS CO 80524 ACORD 25 (2010105) CJ 19tStS-ZU1U AUUKU UUKNUKAI IUN. Au rights reserves. The ACORD name and logo are registered marks of ACORD AGENCY CUSTOMER ID: LOC #: AC")?" ADDITIONAL REMARKS SCHEDULE Page of AGENCY Western Community Ins Co NAMED INSURED NORTH FORK NATIVE PLANTS INC % JEFF KLAUSMANN & TIM WATERS PO BOX 1115 D R I G G S I D 83422 POLICY NUMBER 868 2 04 CARRIER NAIC CODE EFFECTIVE DATE: ADDITIONAL REMARKS THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, FORM NUMBER: FORM TITLE: CITY OF FORT COLLINS is listed as an additional insured per endorsements CG 20 15 0 1 /88) I DCA 389 (01 /04) Waiver of subrogation applies per endorsement CIS 24 04 00/93) ACORD 101 (2008/01) © 2008 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD