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HomeMy WebLinkAboutGRAYCOR CONSTRUCTION COMPANY INC - INSURANCE CERTIFICATE (5)ACORD® �� CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DD/YYYY) 5/18/2017 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 ACIG Insurance Agency, Inc. 2600 N. Central Ex Wy. Suite 800 Richardson, TX 75080 CONT NAMEACT PHONE FAX A/c No Ext : 972-702-9004 A/c No): 972-687-0604 E-MAIL ADDRESS: accountmanagers@acig.com INSURERS AFFORDING COVERAGE NMC1f INSURERA: American Contractors Ins. Co. RRG 12300 www.acig.com INSURED Graycor Construction Company Inc. Two Mid America Plaza, Suite 400 INSURER B : ACIG Insurance Company 19984 INSURERC: INSURERD: Oakbrook Terrace IL 60181 INSURER E : INSURER F : COVERAGES CERTIFICATE NUMBER: 35714711 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. INBR LTR OF INSURANCE ADDLSUBRTYPE INSD WVD POLICY NUMBER POLICY EFF MM/DDIYYYY POLICY EXP MMIDD/YYYY LIMITS A `/ COMMERCIAL GENERAL LIABILITY GL17A00016 6/1/2017 6/1/2018 EACH OCCURRENCE $ 5,000,000 A A CLAIMS -MADE ,/ OCCUR GL17B00016(GL XS) GL17C00016 (GL XS) 6/1/2017 6/1/2017 6/1/2018 6/1/2018 DAMAGE TO RENTED PREMISES Ea occurrence $ 100,000 MED EXP (Any one person) $ 5,000 PERSONAL & ADV INJURY $ 5,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 5,000,000 POLICY Z PRO- JECT LOC PRODUCTS - COMP/OP AGG $ 5,000,000 $ OTHER: A AUTOMOBILE LIABILITY AL17000008 6/1/2017 6/1/2018 EOMaBIINdEeDiSINGLELIMIT $ 5,000,000 BODILY INJURY (Per person) $ ANY AUTO OWNED SCHEDULED AUTOS ONLY AUTOS BODILY INJURY (Per accident) $ HIRED NON -OWNED AUTOS ONLY AUTOS ONLY PROPERTYDAMAGE Per accident $ UMBRELLA LIAB HCLAIMS-MADE OCCUR EACH OCCURRENCE $ AGGREGATE $ EXCESS LIAB DED RETENTION $ $ B B B WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y / N ANYPROPRIETORlPARTNERlEXECUTIVE OFFICER/MEMBEREXCLUDED? ❑N NIA WCA000010017 WCA000005917 WCA000013217 6/1/2017 6/1/2017 6/1/2017 6/1/2018 6/1 /2018 6/1/2018 �/ STATUTE EOT RH E.L. EACH ACCIDENT $ 1,000,000 E.L. DISEASE - EA EMPLOYEE $ 1,000,000 B (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below WCA000020017 6/1 /2017 6/1 /2018 I 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) Re: Contractor License --See Attached Remarks Schedule -- License City Of Fort Collins P.O. Box 580 330 S. College Ave. Fort Collins CO 80522-0580 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 ` Michael J. O'Neill ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD 35714711 1 GRAYCOR 1 17/16 GL 10 AL WC I Kathy Wilson 1 5/18/2017 1:00:44 PM (CDT) I Paqc L of 2 This certificate cancels and supersedes ALL previously issued certificates. AGENCY CUSTOMER ID: GRAYCOR LOC #: ACORO ADDITIONAL REMARKS SCHEDULE Page of AGENCY ACIG Insurance Agency, Inc. NAMED INSURED Graycor Construction Company Inc. Two Mid America Plaza Suite 400 Oakbrook Terrace IL 66181 POLICY NUMBER CARRIER NAIC CODE EFFECTIVE DATE: ADDITIONAL REMARKS THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, FORM NUMBER: 25 FORM TITLE: Certificate of Liability (03/16) HOLDER: City Of Fort Collins ADDRESS: P.O. Box 580 330 S. College Ave. Fort Collins CO 80522-0580 AL - If these policies are cancelled, non -renewed or materially changed, 60 days notice, except 10 days for nonpayment of premium, will be mailed to the Certificate Holder. GL - If these policies are cancelled, non -renewed or materially changed, 60 days notice, except 10 days for nonpayment of premium, will be mailed to the Certificate Holder. WC - If these policies are cancelled, non -renewed or materially changed, 60 days notice, except 10 days for nonpayment of premium, will be mailed to the Certificate Holder. ACORD 101 (2008/01) © 2008 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD ADDENDUM/DOO 35714711 1 GRAYCOR 1 17/16 GL 10 AL WC I Kathy Wilson 1 5/18/2017 1:00:44 PM (CDT) I Page 2 of 2 This certificate cancels and supersedes ALL previously issued certificates.