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HomeMy WebLinkAboutJAX INC - INSURANCE CERTIFICATE (2)® DATE (MM/DD/YYYY ACO ) CERTIFICATE OF LIABILITY INSURANCE 12/21/2017 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 CONTANAME: Kylie Carey, CISR Flood and Peterson PHONE o Ext: (970) 266-7148 �X No: (970)506-6845 JAIC,PO Box 578 E-MAIL ADDRESS: KCarey @F1oodPeterson.com INSURER(S) AFFORDING COVERAGE NAIC # Greeley CO 80632 INSURERA:Acadia Insurance Company 31325 INSURED INSURER B:Firemen Is Insurance Company of 21784 Jax, Inc. INSURERC:Pinnacol Assurance 41190 P.O. Box 469 INSURERD:Zurich American Insurance Company INSURER E Be11Vlle CO 80512 INSURERF: COVFRAGFS CFRTIFICATF NIIMRFR•CL17122121107 RF\/ICIn K1 NIIIIARGR- 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 I TYPE OF INSURANCE ADDL SUBR POLICY NUMBER POLICY EFF MM/DD/VYVY POLICY EXP MM DDNYYY LIMITS A X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE X❑ OCCUR EACH OCCURRENCE $ 1,000,000 DAMAGE TO RENTED PREMISES Ea occurrence $ 500, 000 MED EXP (Any one person) $ 10,000 CPA3155842 1/1/2018 1/1/2019 PERSONAL & ADV INJURY $ 1f000,000 GEN'L AGGREGATE LIMIT APPLIES PER: POLICY ❑PRO JECT X LOC GENERAL AGGREGATE $ 2,000,000 PRODUCTS - COMP/OPAGG $ 2,000,000 PERLO $ OTHER: AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea accident $ 1,000,000 X BODILY INJURY (Per person) $ B ANY AUTO ALL OWNED SCHEDULED AUTOS AUTOS CAA3115682 1/1/2018 1/1/2019 BODILY INJURY (Per accident) $ HIRED AUTOS X NON -OWNED AUTOS X PROPERTY DAMAGE Per accident $ Uninsured motorist combined $ 1,000,000 X UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 5,000,000 AGGREGATE $ 5,000,000 A EXCESS LIAB CLAIMS -MADE DED 'I 'iRETENTION $ CPA3155842 1/1/2018 1/1/2019 WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y/W X PER OTH- STATUTE ER E.L. EACH ACCIDENT $ 500,000 C ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? ❑N (Mandatory in NH) If yes, describe under N/A 4161344 1/1/2018 1/1/2019 E.L. DISEASE - EA EMPLOYE $ 500, 000 DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT $ 500,000 D I Worker' Compensation WC969190005 1/1/2018 1/1/2019 500,000/500,000/500,000 Other States Coverage - IA DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) City of Fort Collins is included as Additional Insured as required by written contract with respects to General Liability arising out of work performed by the named insured. City of Fort Collins P.O. Box 580 Fort Collins, CO 80522-0000 L;ANL;tLLA I IUN 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 Carey, CISR/KCAREY � � � © 1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25 (2014/01) The ACORD name and logo are registered marks of ACORD