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HomeMy WebLinkAboutFMLASOURCE INC - INSURANCE CERTIFICATE (6)' 1 ® ACORO CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DDlYYYY) 1/1/2017 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 endorsements . PRODUCER CONTACT NAME: Van Wagner Agency PNONE _. _ FAx PO Box 9017 . 800-735-1588 888-290-0302 E-MAIL request@sterlingrisk.com 135 Crossways Park Drive ADDRESS-___--__._ _ Woodbury NY 11797 INSURER(SjAFFORDING COVERAGE NAIC # INSURER A: Granite State Insurance Company 23809 INSURED INSURER B :The Hartford 1914 FMLASource, Inc. INSURER Clexington-Insurance Company 19437 455 N.Cityfront Plaza Dr,13thF - "-" -- --- Chicago IL 60611-5503 INSURERERD: INSURER E : rn\/1=RAnpq rl=0TIGIrATt= MIIMRCR• 1'19472fi.'11G RFVICIr1M MIIMRFR- 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 INSD WVD POLICY NUMBER POLICY EFF POLICY EXP MM/DD/YYYY MMlDDIYYYY LIMITS A X COMMERCIAL GENERAL LIABILITY 02LX00899647712002 1/1/2017 1/1/2018 !. EACH OCCURRENCE ''.. $1,000,000 CLAIMS -MADE x� OCCUR , PREMISES occurrence) $1,000,000 MED EXP (Any one person) _ $5,000 LIE, - PERSONAL & ADV INJURY 1 $1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $3,000,000 POLICY PRO- ❑ JECT LOC PRODUCTS •COMP/OP AGO $1,000,000 $ OTHER: A AUTOMOBILE LIABILITY 02CA0661436568 1/1/2017 1/1/2018 Ea accident $1,000,000 BODILY INJURY (Per person) _ $ ANY AUTO ALL OWNED SCHEDULED AUTOS AUTOS BODILY INJURY (Per accident) $ X NON -OWNED XHIRED AUTOS AUTOS PROPERTY DAMAGE Per accident _ $ $ A X UMBRELLA LIAB X OCCUR 29UD00406732717000 1/1/2017 1/1/2018 EACH OCCURRENCE $15,000,000 AGGREGATE $15,000,000 EXCESS LIAB CLAIMS -MADE DED X RETENTION $10,000 I $ B WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y / N ANY PROPRIETOR/PARTNER/EXECUTIVE AOFFICER/MEMBER EXCLUDED? (Mandatory in NH) N/A 12WEPK5818 1/1/2017 ',' 1/l/2018 X STATUTE 1 : ERH E L EACH ACCIDENT $1,000,000 E L DISEASE - EA EMPLOYEq $1,000,000 If yes, describe under DESCRIPTION OF OPERATIONS below j _ E.L. DISEASE -POLICY LIMIT 1 $1,000,000 A C Professional Liability Privacy & Network Sec Ins 02LX00899647712002 052298041 ill/2017 1/1/2018 'Per Occurrence 1,000,000 11,12017 1/1/2018 Aggregate 3,000,000 Limit $3,000,000 Retro date 1/1/14 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) The City of Fort Collins, its officers, agents and employees are included as additional insureds as respects to General Liability when required by WRITTEN CONTRACT prior to a loss. UhK I IFIGA I h HULUhK GANGtLLA I IUN Du vdys SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE City of Fort Collins THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 215 N. Mason Street ACCORDANCE WITH THE POLICY PROVISIONS. 2nd Floor Fort Collins, CO 80522 AUTHORIZED REPRESENTATIVE © 1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25 (2014/01) The ACORD name and logo are registered marks of ACORD