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HomeMy WebLinkAboutT & T ELECTRIC COMPANY INC - INSURANCE CERTIFICATE (5)ACORD® CERTIFICATE OF LIABILITY INSURANCE DATE 229/20117 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 Lowry 7501 E. Low Blvd. Denver, CO 80230-7006 CONTACT NAME: _ PHONE FAX 1No. Extl: A/C No): E-MAIL ADDRESS: INSURER(S) AFFORDING COVERAGE NAIC # INSURER A: Plnnacol Assurance 41190 INSURED T & T Electric Company Inc 1824 Aspen Circle INSURER B : INSURER C : Pueblo, CO 81006 INSURERD: 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. I�TR TYPE OF INSURANCE AD L SUBR POLICY NUMBER POLICY EFF POLICYDEXP OMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ _ CLAIMS -MADE u OCCUR DA EMINVFO R N ED PREMISES Ea occurrence $ MED EXP (Arty one person) $ PERSONAL & ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATEPI $ POLICY ❑ JECT LOC F7 PRODUCTS - COMP/OP AGG $ $ OTHER: AUTOMOBILE LIABILITY COa accMBINED SINGLE LIMBident $ BODILY INJURY (Per person)- $ ANY AUTO OWNED SCHEDULED AUTOS ONLY AUTOS BODILY INJURY (Per accident) $ HIRED NON -OWNED AUTOS ONLY AUTOS ONLY PROPERTY DAMAGE Par accident _ $ $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ AGGREGATE $ EXCESS LIAB CLAIMS -MADE DED RETENTION $ A WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y ANYPROPRIETOR/PARTNER/EXECUTIVE ❑ OFFICERIMEMBEREXCLUDED? (Mandatory in NH) N/A 4007696 01/01/2018 01/01/2019 X PER OTH STATUTE ER E.L. EACH ACCIDENT $1,000,000 E.L. DISEASE - EA EMPLOYEE $ 1,000,000 It yes, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT $ 1 ,000,000 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if 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. Excluded (If any) : Timothy O Miller, Katherine Miller 1856597 City of Fort Collins P.O Box 580 Fort Collins, CO 80522 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 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 OPERATIONS/LOCATIONS/VEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT (CONT) AGENCY CUSTOMER ID: LOC #: N/A N/A ACORN® 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 EFFECTNEDATE: 12/29/2017 THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, FORM NUMBERAcord 2 ((2016/03FORM TITLE: Certificate of LlabilltY 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 (2003/01) © 2008 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD