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HomeMy WebLinkAboutMASON STREET TIRE LLC DBA BIG O TIRES - INSURANCE CERTIFICATEDATE (MM/DD/YYYY) �® CERTIFICATE OF LIABILITY INSURANCE 8/28/2017 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 Stephanie J Huber NAME: P Security First Insurance Agency PA//CNNo Ext: (844)2H2-6930 FAX No: (303)730-2930 7851 S. Elati Street ADDRESS:shuber@securityfirstia.com Suite 100 INSURER(S) AFFORDING COVERAGE NAIC # Littleton CO 80120 INSURERA:Continental Western Insurance 10804__ INSURED INSURER B:Em to ers Compensation Insurance 11512 Mason Street Tire LLC, DBA: Big O Tires INSURERC: c/o Lautzenheiser Management INSURERD: 2121 Midpoint Dr Ste 220 INSURER E: _ Ft. Collins CO 80525 INSURER F : COVERAGES CERTIFICATE NUMRFR-17/18 GL CAU WC XS 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. INSR LTR TYPE OF INSURANCE ADDL SUBR POLICY NUMBER POLICY EFF MMIDD/YYYY POLICY EXP MM/DD/YYYY LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS -MADE j� OCCUR A AGE ToA PREM SES Ea occur RENTEence $ 300,000 MED EXP (Any one person) $ 10,000 X G0303951824 10/10/2017 10/10/2018 PERSONAL 8 ADV INJURY $ 1,000,000 GENT AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 X POLICY PRO JECT EILOC PRODUCTS - COMP/OPAGG $ 2,000,000 GL Ultra Plus $ OTHER: AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea ccident a $ 1,000,000 X BODILY INJURY (Per person) $ A ANY AUTO ALL OWNED SCHEDULED AUTOS AUTOS X G0303951824 10/10/2017 10/10/2018 BODILY INJURY (Per accident) $ PROPERTY DAMAGE Pacc er ident $ NON -OWNED HIRED AUTOS AUTOS Medical payments $ 5,000 X UMBRELLA LIAB OCCUR EACH OCCURRENCE $ 2,000,000 AGGREGATE $ 2,000,000 A EXCESS LIAB CLAIMS -MADE DED I I RETENTION$ $ G0303951824 10/10/2017 10/10/2018 WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y / N X PER OTH- STATUTE ER ANY PROPRIETOR/PARTNER/EXECUTIVE E.L. EACH ACCIDENT $ 1,000,000 OFFICER/MEMBER EXCLUDED? ❑ B (Mandatory in NH) N/A EIG105857009 10/7/2017 10/7/201B E.L. DISEASE - EA EMPLOYEE $ 1,000,000 If yes, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE POLICY LIMIT $ 1,000,000 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) Additional Insured: The City of Fort Colins per form CLCGO013 The City of Fort Collins Purchasing Department PO Box 580 Fort Collins, CO 80522 I:AN1L,tLLA 1 IL)N 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 Tim Van Denend/SHUBER- © 1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25 (2014/01) The ACORD name and logo are registered marks of ACORD INS025 (201401)