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HomeMy WebLinkAbout210510 GK PLUMBINGWorkmanCompWheatRidge`144' Wheat Ri' e i C;OMMUNITy DEVELOPMENT 7500 W. 29'^ Avenue ' Wheat Ridge, CO 80033 `0: (303)235-2855 ` F: (303)235-2857 Contractor Waiver for Workers' Compensation Insurance I, (print your name), Gueorgui Karimov verify that I am the sole owner or partner of (company name): GK Plumbing 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 contractor's license from the City of Wheat Ridge and will be listed on the permit. Signature: 6:LoeC lt/ Date: 08/09/2022 AC40R" CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DD/YYYY) 08/09/2022 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 Daniel Valle NAME: JOHN M BROWN INSURANCE AGENCY INC AICNNo Ext): 888-973-0016 AIS No): 7736572010 ADDRESS: daniely@farmerbrown.com 21750 Hardy Oak Blvd Ste 104 INSURER(S) AFFORDING COVERAGE NAIC # INSURERA: Accredited Casualty and Surety Company San Antonio TX 78258-4946 INSURED INSURER B : CLAIMS -MADE � OCCUR INSURER C: GK Plumbing INSURER D : 350 W 114th Ave Unit 306 INSURER E : $ 100,000 INSURER F: $ 5,000 Northglenn CO 80234 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 MMIDD/YYYY POLICY EXP MMIDD/YYYY LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS -MADE � OCCUR DAMAGETORENTED PREMISES Ea occurrence $ 100,000 MED EXP (Any one person) $ 5,000 PERSONAL &ADV INJURY $ 1,000,000 A Y Y 1ABPCO05127919900 11/21/2021 11/21/2022 AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 GEN'L X POLICYEl PRO - [::]$PRODUCTS JECT - 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 UMBRELLA LAB OCCUR EACH OCCURRENCE $ AGGREGATE $ EXCESS LAB CLAIMS -MADE DED RETENTION $ $ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY YIN PER OTH- STATUTE ER ANYPROPRIETOR/PARTNER/EXECUTIVE E.L. EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? ❑ NIA E.L. DISEASE - EA EMPLOYEE $ (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT $ Business Personal Property Limit o Insurance 5,000 A 1ABPCO05127919900 11/21/2021 11/21/2022 DESCRIPTION OF OPERATIONS I LOCATIONS /VEHICLES (ACORD 101, Additional Remarks Schedule, maybe attached if more space is required) CERTIFICATE HOLDER CANCELLATION City of Wheat Ridge 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 ©198#2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD -a 0 COLORADO D"mkoffliont 04 Rogula" A9wK6" A04111 Ark Cokw-4W State Examining Board of Plumbers Gueorgui Karimov Master Plumber License Type 0310112021 License Et6ective Date MP.03000420 License Number gueolzf,� �azwv 6 --, 02/28/2023 License Exporawn We ACTIVE License Status I COLORADO Pepattment of Regulatory Agencies Colorado State Plumbing Board GK Plumbing Plumbing Contractor License Type 03/01/2021 License Effective Date PC.0004106 License Number 02/28/2023 License Expiration Date ACTM License status G U L c 1z &11.(A' )2CLI2 i `t/t ©V K -f ,