12000000062 Contract

• Contract/PO #: 12000000062
• Contractor Name: Consolidated Mutual Water Company
• Contract Type: Grant
• Water District: 7
• County: Jefferson
• Loan Projects - Doc Type: Contract Documents

.' ® DATE(MM/DD/YYYY)
A�OR° CERTI! :ATE OF LIABILITY INSI.ANCE 2/1/2012
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 NAME: Account Manager
Van Gilder Insurance Corp. ,PA/cH°."No A.Ext):[phone] (Aic,N o):[phone]
Suite
1515 Wynkoop Street ADDREss:certificateCa�v Ic.com
Suite 200 9
Denver CO 80202 INSURER(S)AFFORDING COVERAGE NAIL#
INSURER A:CL-St. Paul Fire&Marine Insu
INSURED INSURER B:Pinnacol Assurance
The Consolidated Mutual Water Company INSURER c:Hanover Insurance
P.O. Box 150068
INSURER D
12700 West 27th Avenue
Lakewood CO 80215 INSURER E: _
INSURER F:
COVERAGES CERTIFICATE NUMBER:1605494527 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 TYPE OF INSURANCE ADDL SUBR POLICY EFF POLICY EXP LIMITS
LTR INSR WVD POLICY NUMBER (MM/DD/YYYY) (MM/DDYYY)
C GENERAL LIABILITY Y Y ZDF892755501 2/1/2012 2/1/2013 EACH OCCURRENCE $1,000,000
DAMAGE TO RETED
X COMMERCIAL GENERAL LIABILITY PREMISES Ea occurrence) $500,000
CLAIMS-MADE X OCCUR MED EXP(Any one person) $5,000
PERSONAL&ADV INJURY $1,000,000
GENERAL AGGREGATE $2,000,000
GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $2,000,000
—1 POLICY JF? X LOC $
C AUTOMOBILE LIABILITY Y AWF898563301 2/1/2012 2/1/2013 COMBINED SINGLE LIMIT $1,000,000
(Ea accident) $
X ANY AUTO BODILY INJURY(Per person) $
ALL OWNED SCHEDULED BODILY INJURY(Per accident) $
AUTOS AUTOS
NON-OWNED PROPERTY DAMAGE
X HIRED AUTOS X AUTOS (Per accident) $
$
A X UMBRELLA LIAB X OCCUR ZUP12P9251012NF 2/1/2012 2/1/2013 EACH OCCURRENCE $20,000,000
EXCESS LIAB CLAIMS-MADE AGGREGATE $20,000,000
DED X RETENTION$10,000 $
B WORKERS COMPENSATION 114652 2/1/2012 2/1/2013 x WC STATU- OTH-
AND EMPLOYERS'LIABILITY TORY LIMITS ER
ANY PROPRIETOR/PARTNER/EXECUTIVE IY—/N� E.L.EACH ACCIDENT $1,000,000
OFFICER/MEMBER EXCLUDED? I I N/A
(Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $1,000,000
If yes,describe under
DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $1,000,000
DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (Attach ACORD 101,Additional Remarks Schedule,if more space is required)
The Colorado Water Conservation Board is included as Additional Insured.
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
Colorado Water Conservation Board ACCORDANCE WITH THE POLICY PROVISIONS.
1313 Sherman St., Room 721
Attn: Ryan Edwards AUTHORIZED REPRESENTATIVE
Denver CO 80203
I ~
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