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HomeMy WebLinkAboutTROY FORMING CONCRETE INC - INSURANCE CERTIFICATE (7)7330/2017 M/DD/YYYY) A�" CERTIFICATE OF LIABILITY INSURANCE (M 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 endorsements . PRODUCER CONTACT Leigh Pullen NAME: g Moody Insurance Agency, Inc. P ONE (303) 824-6600 FAX No ; (303) 370-0118 8055 East Tufts Avenue ADDRESS:leigh.pullen@moodyins.com Suite 1000 INSURERS AFFORDING COVERAGE NAIC N Denver CO 80237 INSURERA:United Specialty Ins Co 12537 INSURED Troy Forming Concrete, Inc. INSURERB:American Select Insurance Co 19992 Denver Caisson Drilling, Inc. INSURERC:Pinnacol Assurance 41190 998 Salida Way INSURER D : I Aurora CO 80011 I INSURER F : COVERAGES CERTIFICATE NUMBER- 17/18 No Forms 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 ADDL SUBR POLICY EFF POLICY EXP LTR TYPE OF INSURANCE POLICY NUMBER MM/DDNYYY MM DIYYYYI LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 A CLAIMS MADE ❑X OCCUR PREMISES Ea occu ence $ 50,000 MEDEXP Any one person $ Excluded ATNATL1770253 4/1/2017 4/1/2018 PERSONAL & ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 POLICY PRO-LOC PRODUCTS-COMPIOPAGG $ 2,000,000 $ OTHER: AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT a Ea ccident $ 1,000,000 BODILY INJURY (Per person) $ 13 X ANY AUTO ALL OWNED SCHEDULED AUTOS AUTOS C2ML3784429 4/1/2017 4/1/2018 BODILY INJURY (Per accident) $ PRO RdT DAMAGE NON -OWNED HIRED AUTOS AUTOS(Par UMBRELLA LIAB OCCUR EACH OCCURRENCE $ AGGREGATE $ EXCESS LIAB CLAIMS -MADE DED RETENTION $ $ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY YIN X PER OTH- STATUTE ER ANY PROPRIETOR/PARTNER/EXECUTIVE E.L. EACH ACCIDENT $ 1,000,000 C (MandatoryEMBER m NH EXCLUDED? ( ry ) NIA 4103394 4/1/2017 4/1/2018 E.L. DISEASE - EA EMPLOYEq $ 1,000,000 If yes, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT 1 $ 1,000,000 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) CERTIFICATE HOLDER CANCELLATION City of Fort Collins P.O. Box 580 Fort Collins, CO 80521 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 Leigh Pullen/LEIPULo����� R��-- ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25 (2014/01) The ACORD name and logo are registered marks of ACORD INS025 (201401)