HomeMy WebLinkAbout106941 SYLVAN DALE GUEST RANCH - INSURANCE CERTIFICATEACCORD® CERTIFICATE OF LIABILITY INSURANCE 8/29/201 / D/YYYY)
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 rights to the certificate holder in lieu of such endorsements .
PRODUCER CONTACT
NAME:
Arthur J. Gallagher Risk Management Services, Inc. PHONE 970-586 4407 FAX
PO Box 4190 (AIC, No,>Jtu _ _ (A/C. No)- 970-586-3370
Estes Park CO 80517 _Aongess _
INSURED SYLVDAL-01
Sylvan Dale Guest Ranch
Susan Jessup
2939 N. County Road 31-D
Loveland CO 80538
DO NOT BILL — TEMPO
INSURER B : Plnnacol Assurance
INSURER D :
C(NfFDAnP-, rFDTIPIrATC' AHIIIAQCD- 12Q721151Q oCvtClnki wlaaDCO.
1190
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
INSD
SUBTS
WVD
POLICY NUMBER
MM/DDIYYYY
MMIDDN YYI
----------"---
LIMITS
A
X
COMMERCIAL GENERAL LIABILITY
CLAIMS -MADE ❑X OCCUR
MOPK07922606
9/1/2017
9/1/2018
EACH OCCURRENCE
$1,000,000
—
$100,000
GEN'L
X
ANfAGEM RENTED—
PREMISES Eaoccurrence
MED EXP (Anyone person)
$5,000
�
PER_S_O_NAL & ADV INJURY
$1,000,000
AGGREGATE LIMIT APPLIES PER:
POLICY PRO ❑
JECT LOC
OTHER:
GENERAL AGGREGATE
$3,000,000
PRODUCTS - COMP/OP AGG
$3,000,000
$
A
AUTOMOBILE
LIABILITY
ANY AUTO
OWNED X SCHEDULED
AUTOS ONLY AUTOS
HIRED NON -OWNED
AUTOS ONLY X AUTOS ONLY
MOPK07922606
9/1/2017
9/1/2018
Ea accidern
$ 1,000,0o0
BODILY INJURY (Per person)
$
X
BODILY INJURY (Per accident)
$
(fOPERTyLjAT7fjCGE—
Per accident)
$
UMBRELLA LIAB
EXCESS LIAR
HCLAIMS-MADE
OCCUR
EACH OCCURRENCE
$
AGGREGATE
$
DIED I I RETENTION $
$
B
WORKERS COMPENSATION
ANDEMPLOYERS'LIABILITY Y/N
ANY PROPRIETOR/PARTNER/EXECUI—
OFFICER/MEMBER EXCLUDED?
(Mandatory in NH)
If yes, describe under
DESCRIPTION OF OPERATIONS below
N/A
2089342
10/1/2016
10/1/2017
STATUTE OT -
STATUTE ER
E.L. EACH ACCIDENT
$100,000
E.L. DISEASE - EA EMPLOYEE
"--'-
$100,000
E.L. DISEASE - POLICY LIMIT
-
$500,000
DESCRIPTION OF OPERATIONS / LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required)
The City, its officers, agents and employees shall be named as additional insured but only with respects to the liability arising out of the
activities of the named insured per form 00 GLO596 00 04 10 - BLANKET ADDITIONAL INSURED.
CERTIFICATE HOLDER CANCELLATION
City of Fort Collins
Purchasing Department
PO Box 580
Ft 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
A40X �4
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