HomeMy WebLinkAboutTCC CORPORATION - INSURANCE CERTIFICATE (1).acoRO� CERTIFICATE QF LIABILiTY INSURANCE DATE(MMlDDIWYY}
�� 4/19/2023
TFlIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. 7H1S
CERTiFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFF�RDEd BY THE pOLICIES
BELOW. THIS CERTIFICATE OF INSURANCE dOES NOT CONSTITUTE A CQNTRACT BETWEEN THE ISSUING INSURER(S), AUTHpRIZED
REPRESENTA7IVE OR PRODUCER, AND THE CERTIFICA7E HOLDEfi.
IMPORTANT: If lhe certificate holder is an ADpITIONAL INSURED, the policy(ies) must be endorsed. if SUBROGATION 15 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 NAME: REReE MCReynolds
Ewing-Leavitt Insurance Agency, Inc. PHo"E .(g70) 679-7346 �C Ho les6��zs-ciso
4U90 Clydesdale Parkway Aoon�ess:renee-mcreynolds@leavitt.com
SUlte 101 INSURER S AFfORDING COVERAGE NAIC k
Loveland CO 80538 INSURERA Selective Insurance Co an of America 012572
INSURED INSURERB Pinnacol Asaurance 41190
TCC CO�Ordt1011 INSURER C
609 Gryfalcon Court Unit D INSURERD:
W171d90r CO 80550 I INSURERF I
COVERAGES CERTIFICATE NUM8ER:23-24 R�VISIpN NUMBER:
THIS IS TO CERTIFY THATTHE POLICIES OF INSURAMCE LISTED BELOW HAVE 6EEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIdD
INDICATED. NONNTHSTANDING ANY REQUIREMENT, TERM OR CONDITIpN OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
CERTIFICATE NlAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,
EXCLUSIONS AND CONDITIQNS OF SUCH PULICIES. IIMITS SHOWN MAY HAVE BEEN ftEDUGED 8Y PAID GLAIMS.
NSR TypE pF INSURANCE ADOI SUBR pOLICY NUMBER MMID�Y/YYYY MM/DDYlYYYY LIMITS
LTR
iC COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE S 1, 000, 0
A CLAIMS M���t � OC:;.iR PREMISES Ea occurrence 5 500, 0
x Blkt Addl In�ureda x 5232569C 5/1/2023 5/1/202a MED EXP (Any one person) S 15,0
x Hlkt Waiver of Subrogation PERSONnL BADVINJURY S 1,000,0
GEN'LnGi;RtGATE UMi�nPPUES PER GENERALAGGREGATE 3 3, 000, 0
POi iCY � E� Q LOC PROpUCTS - COMPIOP AGG S
3,000,0
AUTOM081LE LIABILRY
A X ANY AUTO
nLL OWNED
AUTOS
x HIREOAUTOS
X Blki Add Insureds
X UMBRELLALIAB
A EXCESS LIAB
SCHEDULEO X
AUTOS
NOM-0WNEO
AUTOS
Blkl YJOS
� OCCUR
CtAIMS-MADE
DEO RETENTION 5
WORKERS COMPENSATION
AND EMALOYERS' LIABILITY Y! N
ANY PROPRIETOR/PARTNER/EXECUTiVE
OfFICER/MEMBERFj(CLllDED? � N!A
B (Mandatory In NH)
It ves. tlescnDe under
A �Contractora' Equipment
5232549C
5/1/2023 I 5/1/202C
Follow Form
32325490
Inel Blankat Naiv�r
oE Subcogation
6021079
5/1/2023 � 571/202a
7/1/2022 � 7/1/2023
52325490
S
COMBINEO SINGLE LIMIT S 1, 000, O
Ea acaGent
BO�1LV INJURY (Per person) S
BO�1LY INJURY (Per ecadentj S
PROPERTY DAMAGE b
Per awtlenl
S
EACH OCCURRENCE E 2,000 0
AGGREGATE E 2,000,0
E
E L EACH ACCIDENT S 500 0
E L DISEASE - EA EMPLOYEE 5 500, 0
E.L DISEASE - POLICY LIMIT S 500 .0
5/1/2023 I 5/1/2026 I LeaseNRentadEQuipmanl
Limit 5250.000
9ESCRlPTION OF OPERAT10N3! LOCATION51 VEliICLES {ACORD 701, Addflfonal Ramarks Schadule, may ba attachad 11 mo�e apaca fa raquir�d)
Re: City Hall Council Areas Renovation, 300 LaPorte Ave, Fort Collins, CO;
Certificate holder is named as additional insured. The insurance evidenced by the certificate will not
reduce coverage or limits and will not be cancelled except after 30 days written notice has been issued
to certificate holder, 10 day notice will apply in the event of non-payment of premium.
CERTIFICATE HOLDER CANCELLATION
City of Fort Collins
Building S Zoning Dept
P O Box 580
Fort Collins, CO 80522
SHOULD ANY OF THE ABOVE �ESCRIBED POLICIES BE CANCE�LED BEFORE
THE EXPIRATION DA7E THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
AUTHORIZ£U REPRESENTATIVE
McReynoldsi r'•.:'t - I
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U 798S-Z014 AGORD GORPUKATION. All flglltS fe4erve
ACORD 25 (201410i) The ACORD name and logo are registered marks of ACQRD
INS025 �zo�ao,l