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HomeMy WebLinkAbout210430 BREIT ELECTRIC - COI_Page_1/ ° ACORNCERTIFICATE OF LIABILITY INSURANCE /YDATE (MM/DDYYY) 05/12/2022 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 Verifly Insurance Services, Inc. DBA Thimble Insurance Services 174 West 4th Street, Suite 204 New York, NY 10014 CONTACT THIMBLE https://support.thimble.com/ NAME:PHONE FAx A/C No Ext): A/C No E-MAIL su ort thimble.com ADDRESS: pI� INSURER(S) AFFORDING COVERAGE NAIC # https://support.thimble.com/ INSURER A : National Specialty Insurance Company 226$ INSURED INSURER B INSURER C Caleb Breitbach BreitElectric, LLC INSURER D Rachel@breitelectric.com 80433 INSURER E INSURER F : https://www.thimble.com/check-policy-status/ COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: 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 INSD SUBR WVD POLICY NUMBER POLICY EFF MM/DD/YYYY POLICY EXP MM/DD/YYYY LIMITS X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE X OCCUR 02/11/2022 11:45 AM 06/1 1/2022 11:59 PM EACH OCCURRENCE $ 2,000,000 DAMAGE TO RENTED PREMISES Ea occurrence $ 1005000 MED EXP (Any one person) $ 5,000 A Y Y IBL-FK2CLMQEB MST MDT* See note On PERSONAL &ADV INJURY $ 2,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: @Xpll'at1011 X POLICY PRO- ❑LOC JECT date below. PRODUCTS -COMP/OP AGG $ 2,000,000 Damage to Property Under Your Control $ 2,500 OTHER: AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ Ea accident BODILY INJURY (Per person) $ ANY AUTO OWNED SCHEDULED AUTOS ONLY AUTOS BODILY INJURY (Per accident) $ PROPERTY DAMAGE $ Per accident HIRED NON -OWNED AUTOS ONLY AUTOS ONLY UMBRELLA LIAB OCCUR EACH OCCURRENCE $ AGGREGATE $ EXCESS LIAB CLAIMS -MADE DED RETENTION $ $ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y/N PER OTH- STATUTE ER ANY PROPRIETOR/PARTNER/EXECUTIVE ❑ OFFICER/MEMBER EXCLUDED? N / A E.L. EACH ACCIDENT $ E.L. DISEASE - EA EMPLOYEE $ (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE -POLICY LIMIT $ EACH OCCURRENCE AGGREGATE DESCRIPTION OF OPERATIONS /LOCATIONS /VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space isrequired) *Please note that the insured has purchased a monthly policy that will automatically extend upon expiration of the policy if the insured pays the appropriate premium. At that time, you will receive a new Certificate of Liability Insurance, evidencing such extension. (coni on form Acord 101) CERTIFICATE HOLDER CANCELLATION city of wheatridge 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 O 1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD AGENCY CUSTOMER ID: Rachel@breitelectric.com LOC #: 1 ADDITIONAL REMARKS SCHEDULE Page 1 of 1 AGENCY NAMED INSURED Verifly Insurance Services, Inc. DBA Thimble Insurance Services Caleb Breitbach BreitElectric, LLC POLICY NUMBER I BL-FK2CLMQEB Rachel@breitelectric.com 80433 CARRIER NAIC CODE National Specialty Insurance Company 22608 EFFECTIVE DATE: 02/11/2022 11:45 AM MST ADDITIONAL REMARKS THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, FORM NUMBER: Acord 25 FORM TITLE: Certificate of Liability Insurance Description of Operations (con't) Episodic Coverage (THSN CG 02 03 02 21) for policy number IBL-FK2CLMQEB until 06/11/2023 11:59 PM MDT ACORD 101 (2008/01) © 2008 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD THSN IL 20 20 10 20 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. DESIGNATED ADDITIONAL INSURED This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE FORM PROFESSIONAL LIABILITY COVERAGE FORM SCHEDULE Name of Designated Person or Organization (including its departments and attached agencies, its directors, officers, officials, employees, representatives and agents): Any person(s) or organization(s) for whom you have agreed in writing in a contract or agreement that such person(s) or organization(s) be added as an additional insured on your policy. E -Mail Address: A. SECTION II — WHO IS AN INSURED is amended to include as an additional insured the person(s) or organization(s) shown in the SCHEDULE above, but only with respect to liability for "bodily inju- ry", "property damage", "personal and advertising injury" or "wrongful acts" caused, in whole or in part, by your acts or omissions or the acts or omissions of those acting on your behalf: 1. In the performance of your ongoing operations; or 2. In connection with your premises owned by or rented to you. However: 1. The insurance afforded to such additional insured only applies to the extent permitted by law; and 2. If coverage provided to the additional insured is required by a contract or agreement, the insur- ance afforded to such additional insured will not be broader than that which you are required by the contract or agreement to provide for such additional insured. B. With respect to the insurance afforded to these additional insureds, the following is added to LIM- ITS OF INSURANCE section of the coverage form If coverage provided to the additional insured is required by a contract or agreement, the most we will pay on behalf of the additional insured is the amount of insurance: 1. Required by the contractor agreement; or 2. Available under the applicable limits of insurance shown in the Declarations; whichever is less. C. If this policy is cancelled or nonrenewed for any reason, we will deliver notice of the cancellation or non -renewal to any Designated Person or Organization shown in the SCHEDULE above at the e- mail address shown above. D. This endorsement shall not increase the applicable limits of insurance shown in the Declaration All other terms and conditions remain unchanged. THSN IL 20 2010 20 © Verifly Insurance Services, Inc. 2020 Page 1 of 1 Includes materials copyrighted by Insurance Services Office, Inc., used with its permission POLICY NUMBER: IBL-FK2CLMQEB COMMERCIAL GENERAL LIABILITY CG 24 04 12 19 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. WAIVER OF TRANSFER OF RIGHTS OF RECOVERY AGAINST OTHERS TO US (WAIVER OF SUBROGATION) This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART ELECTRONIC DATA LIABILITY COVERAGE PART LIQUOR LIABILITY COVERAGE PART POLLUTION LIABILITY COVERAGE PART DESIGNATED SITES POLLUTION LIABILITY LIMITED COVERAGE PART DESIGNATED SITES PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE PART RAILROAD PROTECTIVE LIABILITY COVERAGE PART UNDERGROUND STORAGE TANK POLICY DESIGNATED TANKS &103:1=19111" Name Of Person(s) Or Organization (s): Any person(s) or organization(s) for whom you have agreed in writing in a contract or agreement that such person(s) or organization(s) be added as an additional insured on your policy. Information required to complete this Schedule, if not shown above, will be shown in the Declarations. The following is added to Paragraph 8. Transfer Of Rights Of Recovery Against Others To Us of Section IV — Conditions: We waive any right of recovery against the person(s) or organization(s) shown in the Schedule above because of payments we make under this Coverage Part. Such waiver by us applies only to the extent that the insured has waived its right of recovery against such person(s) or organization(s) prior to loss. This endorsement applies only to the person(s) or organization(s) shown in the Schedule above. CG 24 04 12 19 ©Insurance Services Office, Inc., 2018 Page 1 of 1 THSN IL 20 20 10 20 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. DESIGNATED ADDITIONAL INSURED This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE FORM PROFESSIONAL LIABILITY COVERAGE FORM SCHEDULE Name of Designated Person or Organization (including its departments and attached agencies, its directors, officers, officials, employees, representatives and agents): city of wheatridge E -Mail Address: A. SECTION II — WHO IS AN INSURED is amended to include as an additional insured the person(s) or organization(s) shown in the SCHEDULE above, but only with respect to liability for "bodily inju- ry", "property damage", "personal and advertising injury" or "wrongful acts" caused, in whole or in part, by your acts or omissions or the acts or omissions of those acting on your behalf: 1. In the performance of your ongoing operations; or 2. In connection with your premises owned by or rented to you. THSN IL 20 2010 20 © Verifly Insurance Services, Inc. 2020 Page 1 of 2 Includes materials copyrighted by Insurance Services Office, Inc., used with its permission THSN IL 20 20 10 20 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. However: 1. The insurance afforded to such additional insured only applies to the extent permitted by law; and 2. If coverage provided to the additional insured is required by a contract or agreement, the insur- ance afforded to such additional insured will not be broader than that which you are required by the contract or agreement to provide for such additional insured. B. With respect to the insurance afforded to these additional insureds, the following is added to LIM- ITS OF INSURANCE section of the coverage form If coverage provided to the additional insured is required by a contract or agreement, the most we will pay on behalf of the additional insured is the amount of insurance: 1. Required by the contractor agreement; or 2. Available under the applicable limits of insurance shown in the Declarations; whichever is less. C. If this policy is cancelled or nonrenewed for any reason, we will deliver notice of the cancellation or non -renewal to any Designated Person or Organization shown in the SCHEDULE above at the e- mail address shown above. D. This endorsement shall not increase the applicable limits of insurance shown in the Declaration All other terms and conditions remain unchanged. THSN IL 20 2010 20 © Verifly Insurance Services, Inc. 2020 Page 2 of 2 Includes materials copyrighted by Insurance Services Office, Inc., used with its permission COMMERCIAL GENERAL LIABILITY CG 20 01 12 19 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. PRIMARY AND NONCONTRIBUTORY - OTHER INSURANCE CONDITION This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART LIQUOR LIABILITY COVERAGE PART PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE PART The following is added to the Other Insurance Condition and supersedes any provision to the contrary: Primary And Noncontributory Insurance This insurance is primary to and will not seek contribution from any other insurance available to an additional insured under your policy provided that: (1) The additional insured is a Named Insured under such other insurance, and (2) You have agreed in writing in a contract or agreement that this insurance would be primary and would not seek contribution from any other insurance available to the additional insured. CG 20 01 12 19 ©Insurance Services Office, Inc., 2018 Page 1 of 1 POLICY NUMBER: IBL-FK2CLMQEB COMMERCIAL GENERAL LIABILITY CG 24 04 12 19 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. WAIVER OF TRANSFER OF RIGHTS OF RECOVERY AGAINST OTHERS TO US (WAIVER OF SUBROGATION) This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART ELECTRONIC DATA LIABILITY COVERAGE PART LIQUOR LIABILITY COVERAGE PART POLLUTION LIABILITY COVERAGE PART DESIGNATED SITES POLLUTION LIABILITY LIMITED COVERAGE PART DESIGNATED SITES PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE PART RAILROAD PROTECTIVE LIABILITY COVERAGE PART UNDERGROUND STORAGE TANK POLICY DESIGNATED TANKS &103:1=19111" Name Of Person(s) Or Organization (s): city of wheatridge The following is added to Paragraph 8. Transfer Of Rights Of Recovery Against Others To Us of Section IV—Conditions: We waive any right of recovery against the person(s) or organization(s) shown in the Schedule above because of payments we make under this Coverage Part. Such waiver by us applies only to the extent that the insured has waived its right of recovery against such person(s) or organization(s) prior to loss. This endorsement applies only to the person(s) or organization(s) shown in the Schedule above. CG 24 04 12 19 ©Insurance Services Office, Inc., 2018 Page 1 of 1 COLORADO Department of Regulatory Agencies Division of Professions and Occupations Below are your electronic wallet cards to use as proof of your license. You can also print your license at any time by visiting www.colorado.gov/dora/DPO_Print_ License and following the instructions listed. If you would like a more durable wallet card option, you can order one for a fee by visiting www.nasbastore.org and selecting the "Colorado License Cards" link on the left hand side of the page. If you prefer, you can also contact NASBA by phone at 1-888-925-5237 or by email at nasbastoregnasba.org. Should you have questions about your credential, or need other information please contact our Customer Service Team at 303-894-7800 or dora_ dpo_ Iicensinggstate.co.us. Colorado Department of Regulatory Agencies Colorado Department of Regulatory Agencies Division of Professions and Occupations Division of Professions and Occupations Electrical Board Electrical Board Breitelectric, LLC Breitelectric, LLC Electrical Contractor Electrical Contractor EC.0102041 05/05/2021 EC.0102041 05/05/2021 Number Issue Date Number Issue Date Active 09/30/2023 Active 09/30/2023 Credential Status jExpire Date Credential Status Expire Date Verify this credential at: dpo lora .g Ve ify this credential at: dpo. lora . v I1�1IlLf / Division Director Ronne Hines Credential lder gnature Division Director. Ronne Hines Credential Holde nature 1560 Broadway, Suite 1350, Denver, CO 80202 P 303.894.7800 F 303.894.7693 dpo.colorado.gov COLORADO Department of Regulatory Agencies Division of Professions and Occupations Below are your electronic wallet cards to use as proof of your license. You can also print your license at any time by visiting www.colorado.gov/dora/DPO_Print_ License and following the instructions listed. If you would like a more durable wallet card option, you can order one for a fee by visiting www.nasbastore.org and selecting the "Colorado License Cards" link on the left hand side of the page. If you prefer, you can also contact NASBA by phone at 1-888-925-5237 or by email at nasbastoregnasba.org. Should you have questions about your credential, or need other information please contact our Customer Service Team at 303-894-7800 or dora_ dpo_ Iicensinggstate.co.us. Colorado Department of Regulatory Agencies Colorado Department of Regulatory Agencies Division of Professions and Occupations Division of Professions and Occupations Electrical Board Electrical Board Breitelectric, LLC Breitelectric, LLC Electrical Contractor Electrical Contractor EC.0102041 05/05/2021 EC.0102041 05/05/2021 Number Issue Date Number Issue Date Active 09/30/2023 Active 09/30/2023 Credential Status jExpire Date Credential Status Expire Date Verify this credential at: dpo lora .g Ve ify this credential at: dpo. lora . v I1�1IlLf / Division Director Ronne Hines Credential lder gnature Division Director. Ronne Hines Credential Holde nature 1560 Broadway, Suite 1350, Denver, CO 80202 P 303.894.7800 F 303.894.7693 dpo.colorado.gov E41114 COLORADO Department of Regulatory Agencies Division of Professions and Occupations Below are your electronic wallet cards to use as proof of your license. You can also print your license at any time by visiting www.colorado.gov/dora/DPO_Print_ License and following the instructions listed. If you would like a more durable wallet card option, you can order one for a fee by visiting www.nasbastore.org and selecting the "Colorado License Cards" link on the left hand side of the page. If you prefer, you can also contact NASBA by phone at 1-888-925-5237 or by email at nasbastoregnasba.org. Should you have questions about your credential, or need other information please contact our Customer Service Team at 303-894-7800 or dora_ dpo_licensinggstate.co.us. Division of Professions and Electrical Board Caleb Thomas Breitbach Master Electrician M E.3000655 Number Active Credential Status Verify this credential at: c e � Division of Professions and Electrical Board Caleb Thomas Breitbach Master Electrician 03/15/2021ME.3000655 03/15/2021 Issue Date Number Issue Date 09/30/2023 Active 09/30/2023 Expiralate Credential Status Expire Date )vI �. Verify this credential at: dpo.chtrado.gpv , 1560 Broadway, Suite 1350, Denver, CO 80202 P 303.894.7800 F 303.894.7693 dpo.colorado.gov ♦SAI City of "� WheatRjdge COMMUNITY DEVELOPMENT 7500 W. 29th Avenue * Wheat Ridge, CO 80033 * O: (303)235-2855 * F: (303)235-2857 Contractor Waiver for Workers' Compensation Insurance I, (print your name), Caleb Breitbach verify that I am the sole owner or partner of (company name): BreitElectric, LLC which has no employees and is not required by the State of Colorado to carry workers' compensation insurance. I further state that if I hire contractors/subcontractors, they are in compliance with the State of Colorado Workers' Compensation insurance requirements, have obtained the required con actor's license from the City of Wheat Rid and wi be lis n the mit. Signature: �✓.,/ Date: / ° ACORNCERTIFICATE OF LIABILITY INSURANCE /YDATE (MM/DDYYY) 04/12/2022 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 Verifly Insurance Services, Inc. DBA Thimble Insurance Services 174 West 4th Street, Suite 204 New York, NY 10014 CONTACT THIMBLE https://support.thimble.com/ NAME:PHONE FAx A/C No Ext): A/C No E-MAIL su ort thimble.com ADDRESS: pI� INSURER(S) AFFORDING COVERAGE NAIC # https://support.thimble.com/ INSURER A : National Specialty Insurance Company 226$ INSURED INSURER B INSURER C Caleb Breitbach BreitElectric, LLC INSURER D Rachel@breitelectric.com 80433 INSURER E INSURER F : https://www.thimble.com/check-policy-status/ COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: 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 INSD SUBR WVD POLICY NUMBER POLICY EFF MM/DD/YYYY POLICY EXP MM/DD/YYYY LIMITS X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE X OCCUR 02/11/2022 11:45 AM 05/1 1/2022 11:59 PM EACH OCCURRENCE $ 2,000,000 DAMAGE TO RENTED PREMISES Ea occurrence $ 1005000 MED EXP (Any one person) $ 5,000 A Y Y IBL-FK2CLMQEB MST MDT* See note On PERSONAL &ADV INJURY $ 2,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: @Xpll'at1011 X POLICY PRO- ❑LOC JECT date below. PRODUCTS -COMP/OP AGG $ 2,000,000 Damage to Property Under Your Control $ 2�rj00 OTHER: AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ Ea accident BODILY INJURY (Per person) $ ANY AUTO OWNED SCHEDULED AUTOS ONLY AUTOS BODILY INJURY (Per accident) $ PROPERTY DAMAGE $ Per accident HIRED NON -OWNED AUTOS ONLY AUTOS ONLY UMBRELLA LIAB OCCUR EACH OCCURRENCE $ AGGREGATE $ EXCESS LIAB CLAIMS -MADE DED RETENTION $ $ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y/N PER OTH- STATUTE ER ANY PROPRIETOR/PARTNER/EXECUTIVE ❑ OFFICER/MEMBER EXCLUDED? N / A E.L. EACH ACCIDENT $ E.L. DISEASE - EA EMPLOYEE $ (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE -POLICY LIMIT $ EACH OCCURRENCE AGGREGATE DESCRIPTION OF OPERATIONS /LOCATIONS /VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space isrequired) *Please note that the insured has purchased a monthly policy that will automatically extend upon expiration of the policy if the insured pays the appropriate premium. At that time, you will receive a new Certificate of Liability Insurance, evidencing such extension. (coni on form Acord 101) CERTIFICATE HOLDER CANCELLATION city of wheatridge 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 O 1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD AGENCY CUSTOMER ID: Rachel@breitelectric.com LOC #: 1 ADDITIONAL REMARKS SCHEDULE Page 1 of 1 AGENCY NAMED INSURED Verifly Insurance Services, Inc. DBA Thimble Insurance Services Caleb Breitbach BreitElectric, LLC POLICY NUMBER I BL-FK2CLMQEB Rachel@breitelectric.com 80433 CARRIER NAIC CODE National Specialty Insurance Company 22608 EFFECTIVE DATE: 02/11/2022 11:45 AM MST ADDITIONAL REMARKS THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, FORM NUMBER: Acord 25 FORM TITLE: Certificate of Liability Insurance Description of Operations (con't) Episodic Coverage (THSN CG 02 03 02 21) for policy number IBL-FK2CLMQEB until 05/11/2023 11:59 PM MDT ACORD 101 (2008/01) © 2008 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD THSN IL 20 20 10 20 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. DESIGNATED ADDITIONAL INSURED This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE FORM PROFESSIONAL LIABILITY COVERAGE FORM SCHEDULE Name of Designated Person or Organization (including its departments and attached agencies, its directors, officers, officials, employees, representatives and agents): Any person(s) or organization(s) for whom you have agreed in writing in a contract or agreement that such person(s) or organization(s) be added as an additional insured on your policy. E -Mail Address: A. SECTION II — WHO IS AN INSURED is amended to include as an additional insured the person(s) or organization(s) shown in the SCHEDULE above, but only with respect to liability for "bodily inju- ry", "property damage", "personal and advertising injury" or "wrongful acts" caused, in whole or in part, by your acts or omissions or the acts or omissions of those acting on your behalf: 1. In the performance of your ongoing operations; or 2. In connection with your premises owned by or rented to you. However: 1. The insurance afforded to such additional insured only applies to the extent permitted by law; and 2. If coverage provided to the additional insured is required by a contract or agreement, the insur- ance afforded to such additional insured will not be broader than that which you are required by the contract or agreement to provide for such additional insured. B. With respect to the insurance afforded to these additional insureds, the following is added to LIM- ITS OF INSURANCE section of the coverage form If coverage provided to the additional insured is required by a contract or agreement, the most we will pay on behalf of the additional insured is the amount of insurance: 1. Required by the contractor agreement; or 2. Available under the applicable limits of insurance shown in the Declarations; whichever is less. C. If this policy is cancelled or nonrenewed for any reason, we will deliver notice of the cancellation or non -renewal to any Designated Person or Organization shown in the SCHEDULE above at the e- mail address shown above. D. This endorsement shall not increase the applicable limits of insurance shown in the Declaration All other terms and conditions remain unchanged. THSN IL 20 2010 20 © Verifly Insurance Services, Inc. 2020 Page 1 of 1 Includes materials copyrighted by Insurance Services Office, Inc., used with its permission POLICY NUMBER: IBL-FK2CLMQEB COMMERCIAL GENERAL LIABILITY CG 24 04 12 19 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. WAIVER OF TRANSFER OF RIGHTS OF RECOVERY AGAINST OTHERS TO US (WAIVER OF SUBROGATION) This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART ELECTRONIC DATA LIABILITY COVERAGE PART LIQUOR LIABILITY COVERAGE PART POLLUTION LIABILITY COVERAGE PART DESIGNATED SITES POLLUTION LIABILITY LIMITED COVERAGE PART DESIGNATED SITES PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE PART RAILROAD PROTECTIVE LIABILITY COVERAGE PART UNDERGROUND STORAGE TANK POLICY DESIGNATED TANKS &103:1=19111" Name Of Person(s) Or Organization (s): Any person(s) or organization(s) for whom you have agreed in writing in a contract or agreement that such person(s) or organization(s) be added as an additional insured on your policy. Information required to complete this Schedule, if not shown above, will be shown in the Declarations. The following is added to Paragraph 8. Transfer Of Rights Of Recovery Against Others To Us of Section IV — Conditions: We waive any right of recovery against the person(s) or organization(s) shown in the Schedule above because of payments we make under this Coverage Part. Such waiver by us applies only to the extent that the insured has waived its right of recovery against such person(s) or organization(s) prior to loss. This endorsement applies only to the person(s) or organization(s) shown in the Schedule above. CG 24 04 12 19 ©Insurance Services Office, Inc., 2018 Page 1 of 1 THSN IL 20 20 10 20 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. DESIGNATED ADDITIONAL INSURED This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE FORM PROFESSIONAL LIABILITY COVERAGE FORM SCHEDULE Name of Designated Person or Organization (including its departments and attached agencies, its directors, officers, officials, employees, representatives and agents): city of wheatridge E -Mail Address: A. SECTION II — WHO IS AN INSURED is amended to include as an additional insured the person(s) or organization(s) shown in the SCHEDULE above, but only with respect to liability for "bodily inju- ry", "property damage", "personal and advertising injury" or "wrongful acts" caused, in whole or in part, by your acts or omissions or the acts or omissions of those acting on your behalf: 1. In the performance of your ongoing operations; or 2. In connection with your premises owned by or rented to you. THSN IL 20 2010 20 © Verifly Insurance Services, Inc. 2020 Page 1 of 2 Includes materials copyrighted by Insurance Services Office, Inc., used with its permission THSN IL 20 20 10 20 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. However: 1. The insurance afforded to such additional insured only applies to the extent permitted by law; and 2. If coverage provided to the additional insured is required by a contract or agreement, the insur- ance afforded to such additional insured will not be broader than that which you are required by the contract or agreement to provide for such additional insured. B. With respect to the insurance afforded to these additional insureds, the following is added to LIM- ITS OF INSURANCE section of the coverage form If coverage provided to the additional insured is required by a contract or agreement, the most we will pay on behalf of the additional insured is the amount of insurance: 1. Required by the contractor agreement; or 2. Available under the applicable limits of insurance shown in the Declarations; whichever is less. C. If this policy is cancelled or nonrenewed for any reason, we will deliver notice of the cancellation or non -renewal to any Designated Person or Organization shown in the SCHEDULE above at the e- mail address shown above. D. This endorsement shall not increase the applicable limits of insurance shown in the Declaration All other terms and conditions remain unchanged. THSN IL 20 2010 20 © Verifly Insurance Services, Inc. 2020 Page 2 of 2 Includes materials copyrighted by Insurance Services Office, Inc., used with its permission COMMERCIAL GENERAL LIABILITY CG 20 01 12 19 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. PRIMARY AND NONCONTRIBUTORY - OTHER INSURANCE CONDITION This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART LIQUOR LIABILITY COVERAGE PART PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE PART The following is added to the Other Insurance Condition and supersedes any provision to the contrary: Primary And Noncontributory Insurance This insurance is primary to and will not seek contribution from any other insurance available to an additional insured under your policy provided that: (1) The additional insured is a Named Insured under such other insurance, and (2) You have agreed in writing in a contract or agreement that this insurance would be primary and would not seek contribution from any other insurance available to the additional insured. CG 20 01 12 19 ©Insurance Services Office, Inc., 2018 Page 1 of 1 POLICY NUMBER: IBL-FK2CLMQEB COMMERCIAL GENERAL LIABILITY CG 24 04 12 19 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. WAIVER OF TRANSFER OF RIGHTS OF RECOVERY AGAINST OTHERS TO US (WAIVER OF SUBROGATION) This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART ELECTRONIC DATA LIABILITY COVERAGE PART LIQUOR LIABILITY COVERAGE PART POLLUTION LIABILITY COVERAGE PART DESIGNATED SITES POLLUTION LIABILITY LIMITED COVERAGE PART DESIGNATED SITES PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE PART RAILROAD PROTECTIVE LIABILITY COVERAGE PART UNDERGROUND STORAGE TANK POLICY DESIGNATED TANKS &103:1=19111" Name Of Person(s) Or Organization (s): city of wheatridge The following is added to Paragraph 8. Transfer Of Rights Of Recovery Against Others To Us of Section IV—Conditions: We waive any right of recovery against the person(s) or organization(s) shown in the Schedule above because of payments we make under this Coverage Part. Such waiver by us applies only to the extent that the insured has waived its right of recovery against such person(s) or organization(s) prior to loss. This endorsement applies only to the person(s) or organization(s) shown in the Schedule above. CG 24 04 12 19 ©Insurance Services Office, Inc., 2018 Page 1 of 1