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HomeMy WebLinkAbout210463 R3W CONSTRUCTIONR3W - COI (1) (1)/ ACORO� CERTIFICATE OF LIABILITY INSURANCE DATE (MMIDDIYYYY) 1 06/03/2022 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 CONTACT NAME: Caleb Kaufman Kaufman Agency HOE A/CNNo Ext): (303) 975-0363 A/c No): E-MAIL ADDRESS: ckaufmanagency@gmail.com ADDRESS: g y@gmail.com 13701 W Jewell Ave. Unit 284 INSURER(S) AFFORDING COVERAGE NAIC # INSURERA: Evanston Ins Co Lakewood CO 80228 INSURED INSURER B: CLAIMS -MADE � OCCUR INSURER C: R3W Construction LLC INSURER D: 28224 Pipe Bearer Ln INSURER E: $ 100,000 Evergreen, CO 80439 INSURER F: $ 5,000 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 ADDLSUBRPOLICY IVSD WVD POLICY NUMBER EFF MM DD YYYY POLICY MM/DD YYYY LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS -MADE � OCCUR RENTE PREM SESOEa occur ence $ 100,000 MED EXP (Any one person) $ 5,000 PERSONAL & ADV INJURY $ 1,000,000 A 3AA503869 09/07/2021 09/07/2022 AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 GEN'L POLICY � PRO ❑ LOC JECT PRODUCTS - COMP/OP AGG $ 2,000,000 $ 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 r $ 1 1 1 1 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 E.L. EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? ❑ N/A (Mandatory in NH) E.L. DISEASE - EA EMPLOYEE $ If yes, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT $ DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) CERTIFICATE HOLDER CANCELLATION ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. City of Wheat Ridge AUTHORIZED REPRESENTATIVE ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD Nams'. TimasNlnbms Cannaale to manual Adorns, 20224 PW serer Ln Oak. 811513080 Evtrgfesn o0 BW3a EXAMINATION RESULT. PASS Congratulator' You have" read the obovanamed eaemirabon. Youwlll be able to army your pass slaluson Ns ICC web&te mMin 4842 businew noWs afl r ywrevm. Pleasw o,mo l your wnitlpa0ne lurlin lctlon rcyou wad, to moral Ilosnsing. A paring more on the tonne on satistes Ibe Rsma lequ,,mems for Imensue oma and aces np 9umaAMMaIIo n,,e wIenn,gee. yytel le must elm enbN all brei Ordinance requlreull OFFICIAL RESULTS Fall FitrNational SWntlarC Building IAIFRUOML NMNOaUL Contractor (B) Nams'. TimasNlnbms Cannaale to manual Adorns, 20224 PW serer Ln Oak. 811513080 Evtrgfesn o0 BW3a EXAMINATION RESULT. PASS Congratulator' You have" read the obovanamed eaemirabon. Youwlll be able to army your pass slaluson Ns ICC web&te mMin 4842 businew noWs afl r ywrevm. Pleasw o,mo l your wnitlpa0ne lurlin lctlon rcyou wad, to moral Ilosnsing. A paring more on the tonne on satistes Ibe Rsma lequ,,mems for Imensue oma and aces np 9umaAMMaIIo n,,e wIenn,gee. yytel le must elm enbN all brei Ordinance requlreull City cel eat COMMUNITY DEVELOP E c 7500 W. 291h Avenue "Wheat Ridge, CO 80033 * O: (303)235-2855 * F: (303)235-2857 Contractor Waiver for Workers' Compensation Insurance i I, (print your name), verify that I am the sole owne 0. r or partner of (company name): which has no employees and is not required by the State of Colorado to carry workers' compensation insurances further state that if I hire contractors/subcontractors, they are in compliance with the State of Colorado Workers' Compensation insurance requirements, nave uu�a��.Cu � y of Wheat Ridge and will be hC ��i �.I I�GV VV����YV�V•v •�vv��vv ••v... �hobtained te required contractor's license from the City Signature Date.a listed on the permit.