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HomeMy WebLinkAboutBLACK TIMBER BUILDERS LLC - INSURANCE CERTIFICATE (5)BLACK-3 OP ID: PB ACORO TE CERTIFICATE OF LIABILITY INSURANCE FD07/11 /2017 Y) (MM/017 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 CONTANAME: CT Paula Blohm Madison Insurance Group PHONE 303-322-0800 F� No: 303-322-0874 600 S. Cherry Street, #900 AIc No xt E Denver, CO 80246 E-MAIL Shanna Jamsay ADDRESS: pblohm madisoninsurance.net INSURE S AFFORDING COVERAGE NAIC # INSURER A:Pinnacol Assurance Company 41190 INSURED Black Timber Builders, LLC INSURERB:COIony Insurance Company 39993 Kyle Meyer INSURER C 219 E. Elizabeth St. Fort Collins, CO 80524 INSURERD: INSURER E : INSURER F : CCYVFROC'FA rFRTiFi%6TF M1 IMRFi2 P;7V!CIn?M hI1lurtr:0. 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. LTR TYPE OF INSURANCE �DDLTSU D POLICY NUMBER MM DDILICYYYYYY MFF M DD/YYLICY YY LIMITS B XICOMMERCWL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,00 CLAIMS -MADE a OCCUR 103 GLOO14825-00 07/12/2017 07/12/2018 PREMISE ToES EREN a occurrence $ 100,00 MED EXP (Any one person) $ 5,00 J PERSONAL & ADV INJURY $ 1,000,00 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,00 POLICY JET 71 LOC PRODUCTS - COMP/OP AGG $ 2,000,00 $ OTHER: AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea accident $ BODILY INJURY (Per person) $ ANY AUTO NOT WITH MADISON ALL OWNED SCHEDULED AUTOS AUTOS BODILY INJURY (Per accident) $ HIRED AUTOS NON -OWNED AUTOS L PROPERTY DAMAGE Per accident $ $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS -MADE AGGREGATE $ DED RETENTION $ $ A WORKERS COMPENSATION AND EMPLOYERS' LIABILITY N ANY PROPRIETOR/PARTNER/EXECUTIVE YIN 4190143 03/01/2017 03/01/2018 X PER TH- STATUTE ER E.L. EACH ACCIDENT $ 100,00 OFFICER/MEMBER EXCLUDED? ❑ N I A (Mandatory in NH) E.L. DISEASE - EA EMPLOYEE $ 100,00 ff yes, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT $ 500,00 DESCRIPTION OF OPERATIONS I LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) GtK I II-IGA I t HULUtK GANGtLLA I IUN CITFTC2 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN The City of Fort Collins ACCORDANCE WITH THE POLICY PROVISIONS. P.O. Box 580 Fort Collins, CO 80522 AUTHORIZED REPRESENTATIVE © 1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25 (2014101) The ACORD name and logo are registered marks of ACORD