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Home My WebLink AboutJETBLACK FILM CO - INSURANCE CERTIFICATEDATE (MM/DD/YYYY) ® CERTIFICATE OF LIABILITY INSURANCE 9/16/2016 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 CONTACT Dustin Nichols NAME: LAKESIDE INSURANCE CENTER, LLC PHONE (303)421-8590 A/C No: (303)531-5433 7728 Vance Drive E-MAIL ADDRESS: dustin@lakeside-insurance.com INSURERS AFFORDING COVERAGE NAIC # ARVADA CO 80003 INSURER A:Philadel hia Insurance Company 23850 INSURED INSURER B : Jetblack Film Co. INSURERC: 324 Jefferson St INSURERD: INSURER E : _ Fort Collins CO 80524 INSURER F: COVERAGES CERTIFICATE NUMBER:16-17 GL, IM 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. INTR TYPE OF INSURANCE ADDL SUER POLICY NUMBER MMIDD POLICY EFF MM/DD POLICY EXP LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 A CLAIMS -MADE ❑X OCCUR DAMAGE TO RENTED PREMISES Ea occurrence $ 100,000 MED EXP (Any one person) $ 1,000 X PHPK1552940 9/16/2016 1/26/2017 PERSONAL 8 ADV INJURY $ 1,000,000 Cancelled GENT AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 3,000,000 X POLICY F7 PRO- JECT LOC PRODUCTS - COMP/OP AGG $ 3,000,000 $ OTHER: AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea accident $ BODILY INJURY (Per person) $ ANY AUTO ALL OWNED SCHEDULED AUTOS I AUTOS BODILY INJURY (Per accident) $ PROPERTY DAMAGE Pe,accident $ NON -OWNED HIRED AUTOS AUTOS $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ AGGREGATE $ EXCESS LIAB CLAIMS -MADE DED I I RETENTION $ $ WORKERS COMPENSATION ANDFMPLOYERS'LIABIL!TY YIN ANY PROPRIETOR/PARTNER/EXECUTIVE PER TH- ____ STATU_TE__.___, E.L. EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? ❑ NIA - --- E.L. DISEASE - EA EMPLOYE (Mandatory in NH) $ If yes, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT $ A Inland Marine PEPK1552940 9/16/2016 1/26/2017 Leased and Rented Equipment $50 , 000 Cancelled DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) Insurance is for the event: Filming for the Decibullz Company on Sunday September 18th, 2016. Certificate Holder is Additional Insured for General Liability as required by written contract subject to the forms, terms and conditions of the policy. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE City of Fort Collins - Risk Management THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN PO BOX 580 ACCORDANCE WITH THE POLICY PROVISIONS. Fort Collins, CO 80522 AUTHORIZED REPRESENTATIVE Dustin Nichols/DUSTN © 1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25 (2014/01) The ACORD name and logo are registered marks of ACORD V INS025 i?nl4n1i