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HomeMy WebLinkAbout465554 GREYHOUND LINES INC - INSURANCE CERTIFICATE (10)ACO ® CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) F12/21/2016 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 endorsements . PRODUCER CONTACT NAME:_ Tanya D. Stephenson Arthur J. Gallagher Risk Management Services, Inc. PHONE �F—aX 250 Park Avenue UVC,_No,Ext) 212-994-7085 lac �. 212 994 7047 3rd Floor E-MAIL . Tanya_Stephenson@ajg.com _ New York NY 10177 INSURER(S)A) AFFORDING COVERAGE NAICN INSURER A: New Hampshire Insurance Com�an 23841 -- -- -- INSURED INSURER 8: National Union Fire Insurance Com ate_ 19445 Greyhound Lines, Inc. INSURERC:American Home Assurance Company 19380 350 N. St. Paul St. — ---- Dallas, TX 75201 INSURERD: INSURER E : rnVFPAnFS r_PPTIFICATF' IUIIMRFD- 1630264063 DF\l1Ci(11U fUI IlUr2FD. 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 I WVD POLICY NUMBER POLICY EFF MNWD/YYYY POLICY EXP MIDD/YYYY LIMITS B X COMMERCIAL GENERAL LIABILITY GL 3629887 12/31/2016 12/31/2017 EACH OCCURRENCE_ $5,000,000 _ CLAIMS -MADE ❑X OCCUR AMAZERENTED PREMISESS Ea occurrence $5,000,000 MED EXP (Any one person) $ _ PERSONAL & ADV INJURY $5,000,000 GENT AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $10,000,000 POLICY jE � LOC PRODUCTS - COMP/OP AGG $5,000,000 E OTHER: B B AUTOMOBILE LIABILITY ANY AUTO CA 1921794 (AOS) j CA1 921 795(MA) CA1921796 (VA) 12/31/2016 12/31/2016 12/31/2016 12/31/2017 12/31/20117 12/31 /20 7 COMOR90 SINGLE LIMIT aacce $5,000,000B ! BODILY INJURY (Per person) $ OWNED ASCHEDULED AUTOS ONLY UTOS HIRED NON -OWNED AUTOS ONLY AUTOS ONLY BODILY INJURY (Per accident) E MA Per accident) $ $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ AGGREGATE $ EXCESS LIAB CLAIMS MADE $ DED RETENTION $ A A A A C WORKERS COMPENSATION AND EMPLOYERS' LIABILITY YIN ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below NIA WC 014649556 (AOS,OR,TX,GA) WC 014649555 (WI,MA) WC 014649552 (FL) I WC 014649557 (MN) WC 014649553 (CA) 12/31/2016 12/31/2016 12/31/2016 12/31/2016 12/31/2016 12/31/2017 12/31/2017 12/31/2017 12/31/2017 12/31 /2017 X STATUTE ERH — E.L. EACH ACCIDENT $5,000,000 E.L. DISEASE - EA EMPLOYEE $5,000,000 E5,000,000 E.L. DISEASE - POLICY LIMIT DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached If more space is required) Workers Compensation: Policy #: WC 014649554 (AZ,IL,NC,NH,NJ, PA,UT,VT) Policy Term: 12/31 /16 to 12/31 /17 Carrier Name: NEW HAMPSHIRE INS CO (NAIC #:23841) Limits: E.L. Each Accident / E.L. Disease -Ea Employee / E.L. Disease -Policy Limit - $5,000,000 City of Fort Collins is included as Additional Insured as required by written contract subject to policy See Attached... CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE City of Fort Collins THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN P O Box 580, 117 North Mason Street ACCORDANCE WITH THE POLICY PROVISIONS. Fort Collins CO 80522 USA AUTHORIZED REPRESENTATIVE © 1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD AGENCY CUSTOMER ID: LOC #: ,4 C ADDITIONAL REMARKS SCHEDULE Page __1 of 1 AGENCY Arthur J. Gallagher Risk Management Services, Inc. NAMED INSURED Greyhound Lines, Inc. 350 N. St. Paul St. Dallas, TX 75201 POLICY NUMBER CARRIER NAIC CODE EFFECTIVE DATE: RLMARK, THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, FORM NUMBER: 25 FORM TITLE: CERTIFICATE OF LIABILITY INSURANCE terms, conditions and exclusions with Greyhound Lines, Inc. for leased location at: 250 Mason Street, Ft. Collins, CO. ACORD 101 (2008/01) 0 2008 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD