HomeMy WebLinkAboutJETBLACK FILM CO - INSURANCE CERTIFICATE (2)Aco O® CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY)
111 1 9/22/2016
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 AIC No; (303)531-5433
(AJC No7728 Vance Drive -MAIL ADDRESS: dustin@lakeside-insurance.com
INSURERS) AFFORDING COVERAGE NAIL 9
ARVADA CO 80003 INSURER A-Philadel hia Ins
INSURED INSURERS:
Jetblack Film Co. INSURER C :
324 Jefferson St INSURER0:
Fort Collins CO 80524 INSURERF: i
rnvGoer_Gc CFRTIGIrATF NI IMRPR•16-17 GL. IM RFVISInN N11MRFR:
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
ADDL
SUER _ - -
POLICY NUMBER
POLICY EFF
MM/DD/YYYY
POLICY EXP
MM/DD
LIMITS
X
COMMERCIAL GENERAL LIABILITY
EACH OCCURRENCE
$ 1,000,000
A
CLAIMS -MADE X 1 OCCUR
AMA To Ea RENoccTEDurrence
PREMISES
$ 100,000
MED EXP (Any one person)
$ 1,000
%
PHPK1552940
9/16/2016
1/26/2017
PERSONAL 8 ADV INJURY
$ 1,000,000
Cancelled
GEN'L AGGREGATE LIMIT APPLIES PER:
GENERAL AGGREGATE
$ 3, 000, 000
PRODUCTS -COMPIOPAGG
$ 3,000,000
PRO-
R POLICY JECT LOC
$
OTHER:
AUTOMOBILE
LIABILITY
COMBINED SINGLE LIMIT
Ea accident
$
BODILY INJURY (Per person)
$
ANY AUTO
BODILY INJURY (Per accident)
$
ALL OWNED SCHEDULED
AUTOS UTOS
NON -OWNED
HIRED AUTOS AUTOS
PROPERTY DAMAGE
Peraccdent
$
$
UMBRELLA LAB
EACH OCCURRENCE
$
HOCCUR
AGGREGATE
$
EXCESS LIAB
CLAIMS -MADE
DED I RETENTION $
$
WORKERS COMPENSATION
AND EMPLOYERS' LIABILITY Y
ANY PROPRIETOR/PARTNER/EXECUTIVE
PER OTH-
STATUTE ER
$
_ _
E.L. EACH ACCIDENT
OFFICER/MEMBER EXCLUDED? ❑
(Mandatory in NH)
N/A
E.L. DISEASE - EA EMPLOYE
$
E.L. DISEASE - POLICY LIMIT
$
If yes, describe under
DESCRIPTION OF OPERATIONS below
A
Inland Marine
PHPK1552940
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)
Re: City of Fort Collins for shooting on Wednesday, Sept. 28
The City of Fort Collins, its officers, agents, employees and volunteers are Additional Insured for
General Liability as required by written contract subject to the forms, terms and conditions of the
policy.
CERTIFICATE HOLDER I-ANI r-LLAIIUN
City of Fort Collins - Risk Management
PO Box 580
Fort Collins, CO 80522
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
tin Nichols/DUSTN��-x�
CP 1988-2014 ACORD CORPORA 1 ION. All rlgntS reserver_
ACORD 25 (2014/01) The ACORD name and logo are registered marks of ACORD
IN S025 r?m am i