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HomeMy WebLinkAboutMORROW HOLDINGS LLC DBA RISK REMOVAL - INSURANCE CERTIFICATE (11)Client#: 1085482 MORROHOL ACORD. CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) 9/27/2017 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 have ADDITIONAL INSURED provisions or 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 any rights to the certificate holder in lieu of such endorsement(s). PRODUCER (CONTACT NAME: Client Manager US[ Colorado, LLC Construction PHONE P.O. Box 7050 E-MA, a° Ezt : 800 873-8500 N, ; 303-831-5295 ADDRESS: den.contractors@usi.com Englewood, CO 80155 800 873-8500 INSURER(S) AFFORDING COVERAGE NAIC; INSURER A : Cincinnati Indemnity 2328Q INSURED INSURER B Morrow Holdings, LLC. dba Risk Removal 6250 Iron Forge Road INSURERC: Timnath, CO 80547 INSURER0: INSURER E : I INSURER F : COVERAGES CFRTIFICATF NIIMRFR- RFVISInNI NI INeRFR- 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 CONTRACTOR 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 ADDUSUBR INSR WVD POLICY NUMBER POLICY EFF POLICY EXP MM/DD/YYYY _ MM/DD/YYYY LIMITS COMMERCIAL GENERAL LIABILITY CLAIMS -MADE u OCCUR $ $ EEAACH�OECCURRENCE PREMISES Ea occurrence MED EXP (Any one person) $ PERSONAL & ADV INJURY $ $ GEN'L AGGREGATE LIMIT APPLIES PER: POLICY ❑ JECOT- LOC OTHER: _ GENERAL AGGREGATE PRODUCTS - COMP/OP AGG $ $ A AUTOMOBILE LIABILITY ANY AUTO AUTOS ONLY AUTOS NED SCHEDULED AHIRUTOS ONLY X NON -OWNED AUTOS ONLY EBA0280557 0/01 /2017 10/01 /201 COMBINED SINGLE LIMIT Ea accident 1,000,000 X X BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ PROPERTY DAMAGE Per accident $ UMBRELLA UAB EXCESS LIAB H OCCUR CLAIMS -MADE EACH OCCURRENCE $ AGGREGATE $ DED I RETENTION $ $ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y / N ANY PRO PRIETOR/PARTNER/EXECUTIVE C OFFICER/MEMBER EXCLUDED? (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below N / A PER OTH- TA UTE ER E.L. EACH ACCIDENT $ E.L. DISEASE - EA EMPLOYEE $ E.L. DISEASE -POLICY LIMIT 1 $ DESCRIPTION OF OPERATIONS ' LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) RE: All Projects City of Fort Collins Purchasing PO Box 580 Fort Collins, CO 80522-0580 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 (2016/03) 1 of 1 #S21582485/M21578737 ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD LKMZP Client#: 1085482 MORROHOL ACORD, CERTIFICATE OF LIABILITY INSURANCE FE ATE (MM/DD/YYYY) s/27/2017 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 have ADDITIONAL INSURED provisions or 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 any rights to the certificate holder in lieu of such endorsement(s). PRODUCER NAME: Client Manager USI Colorado, LLC Construction A No, Ext : 800 873-8500 ac No): 303-831-5295 P.O. Box 7050 E-MAIL ADDRESS: den.contractors@usi.aom Englewood, CO 80155 INSURER(S)AFFORDING COVERAGE NAIC# 800 873-8500 INSURER Acindnnom kid nity 23280 INSURED INSURER B Morrow Holdings, LLC. dba Risk Removal — -- - 6250 Iron Forge Road INSURERC: — INSURER D : Timnath, CO 80547 COVERAGES CERTIFICATE NIIMRFR- RFtnclnll NI MMIRGR• 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 CONTRACTOR 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. LTFi TYPE OF INSURANCE ADDLSUBR NSR WVD POLICY NUMBER POLICY EFF MWDDfYYYY LIMITS COMMERCIAL GENERAL LIABILITY CLAIMS -MADE LIOCCUR EACH OCCURRENCE $ $ PREMISES Ea occurrence MED EXP (Any one person) $ PERSONAL & ADV INJURY $ $ GEN'L AGGREGATE LIMIT APPLIES PER: PRO POLICY JECT LOC OTHER: GENERAL AGGREGATE PRODUCTS - COMP/OP AGG $ $ A AUTOMOBILE LIABILITY X ANY AUTO OWNED SCHEDULED AUTOS ONLY AUTOS X AUTOS ONLY X NON -OWNED AUTOS ONLY EBA0280557 0/01/2017 10/01/201 COMBINED SINGLE LIMIT Ea accident 1,000,000 BODILY INJURY (Per person) $ BODILY INJURY Per accident ( ) $ PROPERTY DAMAGE Per accident $ EACH OCCURRENCE $ $ UMBRELLA LIAR EXCESS LIAB H OCCUR CLAIMS -MADE AGGREGATE $ DED I I RETENTION $ $ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y / N ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? (Mandatory in NH) If es, describe under DESCRIPTION OF OPERATIONS below N/A I PER OTH- IFIR E.L. EACH ACCIDENT Is E.L. DISEASE - EA EMPLOYEE $ E.L. DISEASE - POLICY LIMIT I $ DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) Re: Lincoln Center City of Fort Collins Purchasing PO Box 580 Fort Collins, CO 80522-0580 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 (2016/03) 1 of 1 #S21582482/M21578737 ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD LKMZP CI ient#: 1085482 MORROHOL ACORD,. CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) s/27/2017 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 have ADDITIONAL INSURED provisions or 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 any rights to the certificate holder in lieu of such endorsement(s). PRODUCER ,CONTACT i NAME: Client Manager USI Colorado, LLC Construction PHONE 800 873-8500 N Ext : A/c No : 303-831-5295 P.O. Box 7050 E-MAIL ADDRESS: den.contractors@usi.com Englewood, CO 80155 800 873-8500 INSURER(S) AFFORDING COVERAGE NAIC # INSURER A: Gncin-11 Indrnnity 23280 INSURED Morrow Holdings, LLC. dba Risk Removal INSURER B 6250 Iron Forge Road INSURERC: Timnath, CO 80547 INSURERD: INSURER E: INSURER F : COVERAGES CERTIFICATE NUMBER: 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 CONTRACTOR 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 ADDL.SUBRPOLIDDICYYYYY NSR WVID POLICY NUMBER ( MOLICYEXP LIMITS $ COMMERCIAL GENERAL LIABILnY _ EACH OCCURRENCE CLAIMS -MADE U OCCUR p PREMISES Ea occurrence $ MED EXP (Any one person) $ PERSONAL & ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: F7 GENERAL AGGREGATE $ POLICY ECOT LOC PRODUCTS - COMP/OP AGG $ $ OTHER: A EBA0280557 AUTOMOBILE LIABILITY 10/01 /2017 10/01 /201 EOa aBINED SINGLE LIMIT ccidenX 1,000,000 BODILY INJURY (Per person) $ ANY AUTO OWNED SCHEDULED AUTOS ONLY AUTOS BODILY INJURY Per accident ( ) $ HIRED NON -OWNED X AUTOS ONLY X AUTOS ONLY PROPERTY DAMAGE Per accident $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ AGGREGATE $ EXCESS LAB CLAIMS -MADE DED f RETENTION $ $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS' LIABILITY Y / N ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? N / A STATUTE E E.L. EACH ACCIDENT $ E.L. DISEASE - EA EMPLOYEE (Mandatory in NH) $ If yes, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT $ DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) As required by written contract or written agreement, the following provisions apply subject to the policy terms, conditions, limitations and exclusions: the City of Fort Collins is included as Additional Insured for work, acts or omissions under the Automobile Liability. City of Fort Collins 215 N. Mason Fort Collins, CO 80524-0000 GANGtLLA I IUN 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 (2016/03) 1 of 1 #S21582483/M21578737 ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD LKMZP Client#: 1085482 MORROHOL ACORD,, CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) 9/27/2017 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 have ADDITIONAL INSURED provisions or 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 any rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTNA EACT Client Manager USI Colorado, LLC Construction NCNo Ext : 800 873-8500 a No): 303-831-5295 P.O. Box 7050 E-MAIL ADDRESS: den.contractors@usi.com Englewood, CO 80155 800 873-8500 K ai INSURER(S) AFFORDING COVERAGE NA _ INSURER A: Cincinnati Indemnity 23280 INSURED INSURER B Morrow Holdings, LLC. dba Risk Removal 6250 Iron Forge Road INSURER C : Timnath, CO 80547 INSURER ID: COVERAGES CFRTIFICATF NIIMRFR- QCtnCinKI rinnnoro. 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 CONTRACTOR 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 LT_R TYPE OF INSURANCE ADDL INSR SUBR WVD POLICY NUMBER POLICY EFF MM/DI POLICY EXP MM/DD/YYYY LIMITS COMMERCIAL GENERAL LIABILITY CLAIMS -MADE OCCUR $ ppEAgqCMH��OEECTCURRENCE PREMISES (e occurrence)$ MED EXP (Any one person) $ PERSONAL & ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: - GENERAL AGGREGATE $ PRODUCTS - COMP/OP AGG POLICY ECTT LOC $ OTHER: EBA0280557 $ 1,000,000 A AUTOMOBILE LIABILITY 10/01/2017 10/01/2018 COMBINED SINGLE LIMIT(Ea accident) X ANY AUTO $ BODILY INJURY (Per person) OWNED SCHEDULED __ AUTOS ONLY AUTOS BODILY INJURY (Per accident) $ X AUTOS ONLY X NON -OWNED AUTOS ONLY PROPERTY DAMAGE Per accident $ $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB _ FIDED CLAIMS -MADE AGGREGATE $ I RETENTION $ $ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y / N ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? N / A PER OTH- T E.L. EACH ACCIDENT $ E.L. DISEASE - EA EMPLOYEE $ (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE -POLICY LIMB 1 $ DESCRIPTION OF OPERATIONS LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, maybe attached if more space is required) The Automobile Liability policy includes an automatic Additional Insured endorsement that provides Additional Insured status to the Certificate Holder only when there is a written contract that requires such status, and only with regard to work performed on behalf of the named insured. City of Fort Collins P.O. 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 \C ACORD 25 (2016/03) 1 of 1 #S21582484/M21578737 ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD LKMZP Client#: 1085482 MORROHOL DATE (MM/DD/YYYY) ACORDTM CERTIFICATE OF LIABILITY INSURANCE 1 9/01/2017 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 NAMEACT Client Manager USI Colorado, LLC Construction PHONE g00 873-8500 F 303-831-5295 A/C No, Eat): AlC, No P.O. Box 7050 ADDDDRESS: den.contractors@usi.com Englewood, CO 80155 INSURER(S) AFFORDING COVERAGE NAIC # 800 873-8500 INSURER A: Cincinnati Insurance Company 110677 INSURED Morrow Holdings,LLC. dba Risk Removal 6250 Iron Forge Road Timnath, CO 80547 INSURER B : INSURER C : INSURER D : INSURER E : INSURER F : rnX1r:0Ar_9=C rFRTIFIrATF NI IMRFR• RFVISI()N 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 CONTRACTOR 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. LTRR TYPE OF INSURANCE ADDLSUBR NSR WVD POLICY NUMBER MM/DDY� MMIDIDY/YYYY LIMITS COMMERCIAL GENERAL LIABILITY CLAIMS -MADE OCCUR I EACH OCCURRENCE $ PREMISES E. occurrence) $ MED EXP (Any one person) $ PERSONAL & ADV INJURY $ L AGGREGATE LIMIT APPLIES PER: PRO - POLICY F JECT LOC r,OTHER: GENERAL AGGREGATE $ PRODUCTS - COMP/OP AGG $ $ A AUTOMOBILE LIABILITY X ANY AUTO ALL OWNED SCHEDULED AUTOS AUTOS X HIRED AUTOS X NON -OWNED AUTOS EBA0280557 10/01/2016 10/01/201 EaaccdenSINGLE LIMIT 1,000,000 BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ $ PROPERTYDAMAGE $ UMBRELLA LIAB EXCESS LIAB CLAIMS -MADE EACH OCCURRENCE $ HOCCUR AGGREGATE $ DED RETENTION $ $ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y / N ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below N / A PER OTH- TA UTE ER E.L. EACH ACCIDENT $ E.L. DISEASE - EA EMPLOYEE - $ E.L. DISEASE - POLICY LIMIT $ _ DESCRIPTION OF OPERATIONS I LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached If more space is required) The Automobile Liability policy includes an automatic Additional Insured endorsement that provides Additional Insured status to the Certificate Holder only when there is a written contract that requires such status, and only with regard to work performed on behalf of the named insured. City of Fort Collins SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Y THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN P.O. Box 580 ACCORDANCE WITH THE POLICY PROVISIONS. Fort Collins, CO 80522 AUTHORIZED REPRESENTATIVE ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25 (2014/01) 1 of 1 The ACORD name and logo are registered marks of ACORD #S21426332/M 18869526 D N KZP