CT2015-142 COI

• Contract/PO #: CT2015-142
• Contractor Name: Supply Irrigating Ditch Company
• Contract Type: Loan
• Loan Projects - Doc Type: Project Checklist

l ® DATE(MM/DD/YYYY)
ACRD CERTIFICATE OF LIABILITY INSURANCE
3/29/2018
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:
F&W Insurance PHONN F,t).303-444-4666 1 FAX.No):303-444-8481
3005 Center Green Drive, Suite 120 E-MAIL
Boulder CO 80301 AnnRFcs•
INSURER(S)AFFORDING COVERAGE NAIC#
INSURER A:American Alternative Insurance Corp 19720
INSURED THESUPP-01 INSURER B:Pinnacol Assurance Company 41190
The Supply Irrigating Ditch Company INSURERC:
PO Box 119
Longmont CO 80502 INSURERD:
INSURER E:
INSURER F:
COVERAGES CERTIFICATE NUMBER: 737153280 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, ADDURI- - POLICY EFF POLICY EXP LIMITS
LTR TYPE OF INSURANCE I INSD WVD POLICY NUMBER IMM/DD/YYYY) (MMIDD/YYYYI
A x COMMERCIAL GENERAL LIABILITY GPPA-PF-605334207000 12/11/2017 12/11/2018 EACH OCCURRENCE $1,000,000
DAMAGE TO
CLAIMS-MADE ) OCCUR PREMISES(EaENTED occurrence) $1,000,000
_MED EXP(Any one person) $10,000
PERSONAL&ADV INJURY $1,000,000
GENL AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $3,000,000
X POLICY JEOT LOC I PRODUCTS-COMP/OPAGG $3,000,000
OTHER: $
AUTOMOBILE LIABILITY !GPPA-PF-605334207000 12/11/2017 12/11/2018 COMBINED SINGLE LIMIT $1,000,000
(Ea accident)
ANY AUTOBODILY INJURY(Per person) $
— OWNED SCHEDULED
AUTOS ONLY AUTOS BODILY INJURY(Per accident) $
— HIRED NON-OWNED PROPERTY DAMAGE $
X AUTOS ONLY X AUTOS ONLY (Per accident)
$
A UMBRELLA LIAB X OCCUR GPPA-PF-605334207000 12/11/2017 12/11/2018 EACH OCCURRENCE $1,000,000
X EXCESS LIAB CLAIMS-MADE AGGREGATE $1,000,000
I DED , RETENTION$ $
B WORKERS COMPENSATION 1447242 1/1/2018 1/1/2019 X PER OTH-
AND EMPLOYERS'LIABILITY �,I N STATUTE ER
ANY PROPRIETOR/PARTNER/EXECUTIVEE.L.EACH ACCIDENT $500,000
NIA
OFFICER/MEMBER EXCLUDED? '
(Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $500,000
If yes,describe under
.DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $500,000
DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required)
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
Colorado Water Conservation Board THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
1313 Sherman Street,Ste 718 ACCORDANCE WITH THE POLICY PROVISIONS.
Denver CO 80203
AUTHORIZED REPRESENTATIVE
CJ ©1988-2015 ACORD CORPORATION. All rights reserved.
ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD