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City of Arvada Risk Management Division 8101 Ralston Rd. Arvada, CO 80002 Telephone: [PHONE REDACTED] Fax: [PHONE REDACTED] Requirements when filing Acord form Certificates of Insurance Effective December 1, 2004 Improperly issued certificates will not be accepted ADDITIONAL INSURED IMPROPERLY ISSUED CERTIFICATES WILL NOT BE ACCEPTED City of Arvada must be shown as an additional insured with regard to: • General Liability • Products Liability • Automobile Liability • Liquor Liability (if applicable) Additional insured forms CG 20-12-07-98 ADDITIONAL INSURED – STATE OR POLITICAL SUBDIVISIONS – PERMITS or CG 20-26-07-04 ADDITIONAL INSURED – DESIGNATED PERSON OR ORGANIZATION should be used. Additional insured wording should read “The City of Arvada is name as an additional insured as their interest may appear with respects to the above policies. Copy of additional insured endorsement must be attached to the certificate. CANCELLATION PROVISIONS • THIRTY (30) days notice of cancellation, except for non-payment of premium DESCRIPTION OF OPERATIONS Please provide a Description of project to which certificate applies. If Certificate is for contractor’s license, please so indicate. COVERAGE, LIMITS AND TERM Λ General Liability Occurrence limit must be at least $1,000,000 Λ General & Prod/Comp Operations Aggregate must be at least $2,000,000 Λ Liquor Liability (if applicable) must be at least $150,000 Λ Auto Liability must be at least $1,000,000 Λ Worker Compensation at least based on statutory limits prescribed by and for the state of Colorado Λ Certificate must be for current policy term CARRIER Carrier must be rated B+ or better, according to Best’s Rating Guide IMPROPERLY ISSUED CERTIFICATES WILL NOT BE ACCEPTED 9/21/05 Revision ---PAGE BREAK--- - - - I DATE (MM/DD/YYYY) .1 ACORD™ CERTIFICA IE OF LIABILITY INSURANCE r; . . ) 'PRODUCER THIS CERTIFICATE IS ISSUED ASA MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE ·1 · ( HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. IN SURERS A FFORDING COVERAGE NAIC # INSURED INSURER A: ABC COMPANY INSURER B: 123 Str~et INSURER C: D·enver , co 80202 INSURER-0: INSURER E: - COVERAGES THE POLICIES.OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAM ED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTAN DIN G " ~:::Y!ReME~DJTin~ nc ' " v rn"Tc ~r.T nc noCUMENT W ITH RESPECT TO WH ICH THI S CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJ ECT T O ALL THE TERMS, EXCLUSIONS AND CONDITIONS .OF SUCH POLICIES. AGGREGATE LIMITS SHOW N MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR ADO"l POLICY EFFECTIVE POLICY EXPIRATION LTR NSRC TYPE OF INSURANCE POLICY NUMBER DATE IMM/DD/YY1 DATE IMM/OD/YYl . -LIMITS - A GENERAL LIABILITY 10/01/04 10/01/05 EACH OCCURRENCE $1 000 ODO X COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED $300 000 PAi= i'!.if t , - CLAIMS MADE OCCUR - MED EXP (Any one person) $10 000 PERSONAL & ADV INJURY $1 000 000 - GENERAL AGGREGATE $2 000 000 - GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP/OP AGG $2 000 000 7 .ix7PRO- • POLICY X JECT nLOC 8 AUTOMOBILE LIABILITY ! 10/01/04 10/01/05 - COMBINED SINGLE LIMIT - ' s1,ooo,ooo X ANY AUTO (Ea accidenl) - ALL OWNED AUTOS BODILY INJURY - $ SCHEDULED AUTOS (Per person) -X HIRED AUTOS ' BODILY INJURY $ X NON-OWNED AUTOS (Per accident) - 'J - PROPERTY DAMAGE (Per accident) $ GARAGE LIABILITY - AUTO ONLY - EA ACCIDENT $ ANY AUTO - I OTHER THAN EA ACC $ AUTO ONLY: AGG $ EXCESS/UMBRELLA LIABILITY • EACH OCCURRENCE - . . . - . . - OCCUR CLAIMS MADE I AGGREGATE ' - $ =l DEDUCllB_LE , $ RETENTION $ , $ C : • ·10/01 ,104 1 G/01/05 I WC STATU- / /OJ/i° WORKERS COMPENSATION ANO - . X Tricv LIMIT.''l EMPLOYERS' LIABILITY E.L. EACH ACCIDENT 1$1 00,000 ANY PROPRIETOR/PARTNER/EXECUTIVE $100,000 OFFICER/MEMBER EXCLUDED? E.L. DISEASE · EA EMPLOYEE If yes, describe under E.L. DISEASE • POLICY LIMIT $500,000' SPECIAL PROVISIONS below OTHER · - · · - - - - DESCRIPTION OF OPERATIONS /LOCATIONS / VEHICLES/ EXCLUSIONS ADDED BY ENDORSEMENT / SPECIAL PROVISIONS Re: Contractors License The City of Arvada is named as an additional insu-red per written agreement witl respects to the gen~~al liability per endorsement (CG 2o -2 6 - o7 - 9·s or ·CG _20-12~07-04).. Endorsement· attached· CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED ~OUCIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL DAYS WRITTEN CITY OF ARVADA NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL ENGINEERJNG DIVISION IMPOSE NO OBLIGATION OR LIABILITY OF ANY K:IND UPON THE INSURER, ITS AGENTS OR 8101 RAL.STON ROAD REPRESENTATIVES. AUT-HORIZED REPRESENTATIVE ARVADA, CO 80002 . . - . - - . - · @ ACORD CORPORATION 1988 ACORD 25 (2001/08) 1 of 3 #S233092/M225441