HomeMy WebLinkAboutAssociated Pool Builders Inc American Casualty Co. Valley Forge Insurance Co., National Fire Ins of Hartford Certificate of Liability Insurance ASSO-02 OP ID:JW
DATE(MMIDDIYYYY)
CERTIFICATE OF LIABILITY INSURANCE 12/2412013
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
Phone:701-258-2800 NAME.;_..._ .... w.. . .._____
Vaaler Insurance/Bismarck
PO Box 933 Fax:701-258-2888 AIC-uo Ex1 _.__..... vC, o
Bismarck,ND 58502 EMAIL
Rollin C.Mehlhoff ADDRESS:
INSURER(S)AFFORDING COVERAGE NAIL SI
INSURER A;American Casualty Co of
INSURED Associated'Pool Builders Inc INSURER B:Valley Forge Insurance Co 20508
Associated Builders A Division _ __.._ ..... ...,.
of APBI,Associated Supply Co. INSURER C:National Fire Ins of Hartford 20478
PO Box 2318 INSURER D:
Bismarck, ND 58502 INSURER E:
INSURER F:.
COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: 1
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 .- _._._.._.............. _.....,_,.,., ..,,,....._.._ _..._.__AO17 5UBR POOLIC:Y EFF POLICY EwXP
LTR .. TYPE OF INSURANCE POLICY NUMBER MMIDDNYYY MMIDDIYYYY LIMITS
GENERAL LIABILITY EACH OCCURRENCE $ 1,000,00
.la�."METQ�r=r�T� ...._. ..._.. _.
B X COMMERCIAL GENERAL LIABILITY 5090912912 0110112014 0110112015 PREMISES Ea occurrence $ 100,00
CLAIMS-MADE 143 OCCUR MED EXP(Any one person) $ 5,00
PERSONAL&ADV INJURY $ 11000,00
X per proj.ago GENERAL AGGREGATE $ 2,000,00
......... ......_ ......... -
GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS COMP/OP AGG $ 2,000,00
PRO-
POLICY X LOC Emp Ben. $ 1 M12
AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT_ 1000,000
_ Ea accidenl __..._. ....,.__?
VC X ANY AUTO 5090912893 0110112014 01101/2015 BODILY INJURY(Per Person) $
ALL OWNED SCHEDULED _. ... _.
AUTOS AUTOS BODILY INJURY(Per accident) $
NON-OWNED PROPERTY DAMAGEtlW $
HIRED AUTOS AUTOS (Weraccidenl),,,
UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 5,000,00
A X EXCESS LIAB CLAIMS-MADE 5090912909 01/0112014 01101/2015 AGGREGATE $ 5,000,00
OED X RPTENTION$ 10000.. $
WORKERS COMPENSATION WC STATU OTH-
AND EMPLOYERS'LIABILITY YIN T RY I I I E
ANY PROPRIETORIPARTNEWEXECUTIVE E L..EACH ACCIDENT" $
OFFICEWMEMBER EXCLUDED? NIA ... .. ..._...- -__..____
(Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $
If yyes,describe under
DESCRIPTION OF OPERATIONS below E.L.DISEASE,-POLICY LIMIT '$
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 161,Additional Remarks Schedule,if more space is required)
CERTIFICATE HOLDER CANCELLATION
BOZEM-1
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
BOzelTlan,City Clerk's Office ACCORDANCE WITH THE POLICY PROVISIONS,
City Hall Suite 102 AUTHORIZED REPRESENTATIVE
PO Box 1230
Bozeman, MT 59771
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ACORD 25(2010105) The ACORD name and logo are registered marks of ACORD