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HomeMy WebLinkAboutT & T ELECTRIC COMPANY INC - INSURANCE CERTIFICATE (4),a`� D® CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DD/YYYY) 12/29/2017 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 have ADDITIONAL INSURED provisions or 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 Pinnacol Assurance 7501 E. Lowry Blvd. Denver, CO 80230-7006 CONTACT NAME: PHONE FAX A/C. N Ext1__ AIL ADDRESS: INSURER(S) AFFORDING COVERAGE NAIL N INSURER A: PInnacol Assurance 41190 INSURED T & T Electric Company Inc 1824 Aspen Circle INSURER B : INSURERC: Pueblo, CO 81006 INSURER D : INSURER E : INSURER F : 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 AD SUB POLICY NUMBER POLICY EFF MM/DD POLICY EXP MMID LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ CLAIMS-MADE L _ -]OCCUR DAMAGE TO IR8NTE-6- PREMISES a occurrence E MED EXP (Any one person) $ PERSONAL & ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ POLICY ^i JE P LOC PRODUCTS - COMP/OP AGG $ $ OTHER: AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea accident $ BODILY INJURY (Per person) E ANY AUTO OWNED SCHEDULED AUTOS ONLY AUTOS BODILY INJURY (Per accident) $ PROPERTY DAMAGE Per accident E HIRED NON -OWNED AUTOS ONLY AUTOS ONLY E UMBRELLA LIAB OCCUR EACH OCCURRENCE $ AGGREGATE $ EXCESS LiAB CLAIMS -MADE DIED I I RETENTION $ A WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANYPROPRIETOR/PARTNER/EXECUTIVE Y/N OFFICERIMEMBEREXCLUDED? (Mandatory in NH) NIA 4007696 01/01/2018 01/01/2019 TH- X STATUTE ER E.L. EACH ACCIDENT E1,000,000 E.L. DISEASE - EA EMPLOYEE f 1,000,000 M yes, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT $ 1,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached H more space is required) nless otherwise stated in the policy provisions, coverage is in Colorado only. Refer to the Acord 101 Additional Remarks Schedule for supplemental cancellation otification information. xcluded (If any) : Timothy Q Miller, Katherine Miller CERTIFICATE HOLDER CANCELLATION 1856600 City of Fort Collins SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE P.O Box 580 THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Fort Collins, CO 80522 ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE Western Group, Inc - Pueblo ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD ACORDs provided by Forms Boss. www.FormsBoss.com; (c) Impressive Publishing 800-208-1977 CERTIFICATE HOLDER COPY IMPORTANT If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). 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). DISCLAIMER The Certificate of Insurance on the reverse side of this form does not constitute a contract between the issuing insurer(s), authorized representative or producer, and the certificate holder, nor does it affirmatively or negatively amend, extend or alter the coverage afforded by the policies listed thereon. DESCRIPTION OF OPERATION S/LOCATIONSNEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT (CONT) AGENCY CUSTOMER ID: N/A _ LOC #: N/A A� ® ADDITIONAL REMARKS SCHEDULE Page 3 of 4 AGENCY Western Group, Inc - Pueblo NAMED INSURED T & T Electric Company Inc 1824 Aspen Circle Pueblo, CO 81006 POLICY NUMBER 4007696 CARRIER Pinnacol Assurance NAIC CODE 41190 EFFECTIVEDATE: 12/29/2017 ADDITIONAL REMARKS THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, FORM NUMBERPc rd 2 ((2016103]FORM TITLE: Certificate of Liability Insurance SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING COMPANY WILL ENDEAVOR TO NOTIFY 10 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO NOTIFY SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE COMPANY, ITS AGENTS OR REPRESENTATIVES. ACORD 101 (2008/01) © 2008 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD