HomeMy WebLinkAboutPOWER SURVEY LLC - INSURANCE CERTIFICATE (3)AC"R" CERTIFICATE OF LIABILITY INSURANCE
DATE (MM/DD/YYYY)
07/18/2018
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 endorsement(s).
PRODUCER
MARSH USA, INC.
1717 Arch Street
Philadelphia, PA 19103
Attn: Philadelphia.certs@Marsh.com Fax: 212-948-0360
CONTACT
NAME:
FAX
PHONE E t ' A/C No):
MAIL
ADDRESS:
-
INSURER S AFFORDING COVERAGE
NAIC # _
INSURER A: Philadelphia Indemnity Insurance Company
18058
CN1013072_78_-POWER-CAS-18-19
_
INSURED
Power Survey LLC
1 County Road
INSURER B : Travelers Indemnity Company of Connecticut
25682
INSURER C : Travelers Property Casualty Co. Of America
25674
INSURER D :
Secaucus, NJ 07094
INSURER E :
INSURER F :
rnvGnAr_Gc rFRTIFIrATF NIIMRFR• CLE-006307808-01 REVISION NUMBER: 2
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
MM/DD/YYYY
POLICY EXP
MM/DD/YYYY
LIMITS
A
X
COMMERCIAL GENERAL LIABILITY
CLAIMS -MADE � OCCUR
PHPK1799168
04/01/2018
04/01/2019
EACH OCCURRENCE
$ 1,000,000
PREMISES Ea oTED
ccurrence)
$ 1,000,000
MED EXP (Any one person)
$ 20,000
PERSONAL & ADV INJURY
$ 1,000,000
GENT AGGREGATE LIMIT APPLIES PER:
X PRO -
POLICY ❑PRO ❑ LOC
J
OTHER:
GENERAL AGGREGATE
$ 2,000,000
PRODUCTS - COMP/OP AGG
$ 2,000,000
B
AUTOMOBILE LIABILITY
X ANY AUTO
X OWNED SCHEDULED
AUTOS ONLY AUTOS
X HIRED NON -OWNED
AUTOS ONLY AUTOS ONLY
P-810-829OB1 62-TCT-1 8
COMP/COLL DED: 1,000
04/01/2018
04/01/2019
COMBINED SINGLE LIMIT
Ea acadent
$ 1,000,000
BODILY INJURY (Per person)
$
BODILY INJURY (Per accident)
$
PROPERTY DAMAGE
$
$
UMBRELLA LIAB
EXCESS LIAB
OCCUR
EACH OCCURRENCE
$
HCLAIMS-MADE
AGGREGATE
$
DED RETENTION $
$
C
WORKERS COMPENSATION
AND EMPLOYERS' LIABILITY YIN
ANYPROPRIETOR/PARTNER/EXECUTIVE
OFFICER/MEMBEREXCLUDED? ❑N
(Mandatory in NH)
If yes, describe under
DESCRIPTION OF OPERATIONS below
NIA
UB-3K403043-18-43-G
04/0112019
X PER OTH-
STATUTE ER
E. L. EACH ACCIDENT
$ 1,000,000
E-L. DISEASE - EA EMPLOYEE
$ 1,000,000
E.L. DISEASE - POLICY LIMIT
$ 1,000,000
DESCRIPTION OF OPERATIONS / LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required)
City of Fort Collins is included as Additional Insured where required by written contract, except for Workers Compensation.
CERTIFICATE HOLDER l,Anl\iCLL.A 1 IVry
City of Fort Collins
222 Laporte Ave.
Fort Collins, CO 80521
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
of Marsh USA Inc.
Manashi Mukherjee 3 0�o.;a�►�=�c- u
V lytftf-2U10 At.VI'Cu t+VI(rVr[AIIvrv. riu nynts rGSCrv�u.
ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD