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HomeMy WebLinkAbout102747 JAX INC - INSURANCE CERTIFICATE (2)AC" © DATE (MM/DD/YYYY) �� CERTIFICATE OF LIABILITY INSURANCE 12/19/2016 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 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 CNTNAME: Kylie Carey, CISR Flood and Peterson ACNE Ems. (970)266-7148 A/C No: (970)506-6845 PO Box 576 onnRlFss•KCarey@floodpeterson.com Greeley CO 80632 INSURERS AFFORDING COVERAGE NAIC # INSURERA:Continental Western Group10804 INSURED Jax, Inc. P.O. BOX 469 Bellvue CO 80512 INSURERB:Pinnacol Assurance 41190 INSURERC:Zurich American Insurance Company INSURERD: INSURER E : INSURER F : COVFRAGFS CFRTIFI^ATF NI IMRFR-CL16121 91 Si 2q DCVICI(1nI Ln IaaDCD- 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 TYPE OF INSURANCE ADDL UBR POLICY EFF POLICY EXP LTR INSD WVP POLICY NUMBER MM/DD/YYYY MM/DD/ LIMITS A X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE L] OCCUR EACH OCCURRENCE $ 1,000,000 DAMAGE TO RENTED PREMISES Ea occurrence $ 500,000 MED EXP (Any one person) $ 5,000 CPA3155842 1/1/2017 1/1/2018 PERSONAL & ADV INJURY $ 1,000,000 GENT AGGREGATE LIMIT APPLIES PER: POLICY a jE O LOC GENERAL AGGREGATE $ 2,000,000 PRODUCTS - COMP/OP AGG $ 2,000,000 PERLO $ OTHER: AUTOMOBILE LIABILITY EOMaBBIINdEDtSINGLE LIMIT $ 1,000,000 BODILY INJURY (Per person) $ AANY AUTO ALL OWNED SCHEDULED AUTOS AUTOS CAA3115682 1/1/2017 1/1/2018 BODILY INJURY Per accident) $ X NON -OWNED HIRED AUTOS X AUTOS PROPERTY DAMAGE Per accident $ Uninsured motorist combined $ 1,000,000 A LIAB X OCCUR EACH OCCURRENCE $ 5,000,000 AGGREGATE $ 5,000,000 AIAB L CLAIMS -MADE RETENTION$ $ CPA3155642 1/1/2017 1/1/2018 B WORKERS COMPENSATION AND EMPLOYERS' LIABILITY YIN ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? N❑ (Mandatory in NH) If yes. describe under NIA 4161344 1/1/2017 1/1/2018 X PER OTH- STATUTE ER _ $ 500,000 E.L. EACH ACCIDENT E.L. DISEASE - EA EMPLOYEE $ 500,000 E.L. DISEASE - POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS below C Workers' Compensation WC969190004 1/1/2017 1/1/2018 Other States Coverage - IA I i DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) City of Fort Collins is included as Additional Insured as required by written contract with respects to General Liability arising out of work performed by the named insured. �Urt I In\.,M I F_ nyLIJCR L ANL t:LL.A I IL)N City of Fort Collins P.O. Box 580 Fort Collins, CO 80522-0000 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 ACORD 25 (2014/01) INS025 on14nT1 K Carey, CISR/KCAREY ''*`e!53 � ©1988-2014 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD