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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 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 IMPROPERLY ISSUED CERTIFICATES WILL NOT BE ACCEPTED INSURED 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 ► THIRTY (30) days notice of cancellation, except for non-payment of premium PROVISIONS DESCRIPTION OF Please provide a Description of project to which certificate applies. OPERATIONS If Certificate is for contractor's license, please so indicate. COVERAGE, • General Liability Occurrence limit must be at least $1,000,000 LIMITS AND TERM • General & Prod/Comp Operations Aggregate must be at least $2,000,000 • Liquor Liability (if applicable) must be at least $150,000 • Auto Liability must be at least $1,000,000 • Worker Compensation at least based on statutory limits prescribed by and for the state of Colorado • 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--- ACORD TMCERTIFICATE OF LIABILITY INSURANCE DATE (MM/DD/YYYY) THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. PRODUCER INSURED ABC COMPANY 123 Street Denver, CO 80202 INSURERS AFFORDING COVERAGE INSURED A: INSURER B: INSURER C: INSURER D: INSURER E: NAIC # COVERAGES 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. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES / EXCLUSIONS ADDED BY ENDORSEMENT / SPECIAL PROVISIONS Re: Contractors License. The City of Arvada is named as an additional insured per written agreement with respects to the general liability per endorsement (CG 20-26-07-98 or -CG .20-12-07-04).. Endorsement attached. CERTIFICATE HOLDER CITY OF ARVADA ENGINEERING DIVISION 8101 RALSTON ROAD ARVADA, CO 80002 CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 30* DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR REPRESENTATIVES. AUTHORIZED REPRESENTATIVE ACORD 25 (2001/08) 1 of3 #S233092/M225441 © ACORD CORPORATION 1988