Loading...
HomeMy WebLinkAbout210471 DAVIS INVESTMENTS LLCCity of Wheat Ridge Waiver (1)1 � 4 IV .. r City of -A Wh6atd COMMUNITY DEVELOPMENT,.ge 7500 W. 291h Avenue * Wheat Ridge, CO 80033 * O: (303)235-2855 * F: (303)235-2857 Contractor Waiver for Workers' Compensation Insurance I, (print your name), , . -- , , "a z,oS verify that I am the sole owner or partner of (company name): which has no employees and is not required by the State of Colorado to carry workers' compensation insurance. 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 contractor's license from the City of Wheat Ridge and will be listed own the permit. Signature: 1'- / - Date: A-, fzo / ACORO° CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DD/YYYY) 06/10/2022 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 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: Ryan W. Slaughter Agency, Inc American Family Brokerage Inc a/c°NNo Ext): (303) 444-1009 FVC No 6000 American Parkway ADDRIESS: rslaught@amfam.com INSURER(S) AFFORDING COVERAGE NAIC # INSURERA: BADS - Penn Star Insurance Madison WI 53783 INSURED INSURER B: INSURER C: Davis Investments LLC Davis, Steven INSURER D: 3209 W. Fairview PI. INSURER E: INSURER F: Denver CO 80211 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 INSD WVD POLICY NUMBER POLICY EFF MM/DD POLICY EXP MM/DD LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS -MADE FJX� OCCUR DAMAGE TO RENTED PREMISES Ea occurrence $ 100,000 MED EXP (Anyoneperson) $ 5,000 PERSONAL&ADV INJURY $ 1,000,000 A PAV0333991 10/22/2021 10/22/2022 GEN'LAGGREGATE LIMITAPPLIES PER: GENERAL AGGREGATE $ 2,000,000 x POLICY PRO- JECT ❑ LOC PRODUCTS - COMP/OPAGG $ 2,000,000 $ OTHER: AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ Ea accident BODILY INJURY (Per person) $ ANYAUTO ALL OWNED SCHEDULED AUTOS AUTOS BODILY INJURY (Per accident) $ PROPERTY DAMAGE $ Per accident HIREDAUTOS NON -OWNED AUTOS UMBRELLA LIAB OCCUR EACH OCCURRENCE $ AGGREGATE $ EXCESS LIAB CLAIMS -MADE DED I I RETENTION $ r $ WORKERS COMPENSATIONPER OTH- AND EMPLOYERS' LIABILITY YIN STATUTE ER ANY PROPRIETOR/PARTNER/EXECUTIVE I OFFICER/MEMBER EXCLUDED? N 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 1 $ DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) CERTIFICATE HOLDER CANCELLATION ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25 (2014/01) 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 City of Wheat Ridge ACCORDANCE WITH THE POLICY PROVISIONS. 5840 W 34th Ave AUTHORIZED REPRESENTATIVE Denver CO 80212 ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25 (2014/01) The ACORD name and logo are registered marks of ACORD { Bamq or�— %E22 , e » B @ @ e o Rk0p \\\\ odead 0222 {\_ NcliC\lN www « 0 RkS 0 c .. Uc�U to= 7200 c 0> (/ I ■z �§k0 « r § \ 7f § % \ L 2 A Q ot7a LU C) V) c ; >e cn5 2 In . o§ ){ { u = _ < \0 {\_ 3 \ ) RkS to= o $gym as 0 2 ) ■ « r § k§/ % a»/ C) V) c ; C \ co k\ e » c � J e w kee kr c 3— \ ƒ(j o ƒ S3D ± m S @ ..� § $ a 5 § q 5zR d f\« i 0E