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Home My WebLink About20001623.tiff AC(�RD CERTIFICATE OF LIABILITY INSURANCE OATF(AAM/D°^Y -- tY 06/20/2000 'RUDUCER (405)840-9090 FAX (405)840-9691 I H15 CI_H I II—ILA I E I5 15511;0 AS A MA T I EK OF IcFFCRM 1 ION-- ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE Ledbetter Insurance Agency, Inc. HOLDER.THIS CERTIFICATE DOES NOT AMEND, EXTEND OR 1000 N.W. Grand Blvd. ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Oklahoma City, OK 73118 INSURERS AFFORDING COVERAGE NSURED INSURER A: Specialty Surplus Ins Co/US Risk Underwrite The Villa at Greeley INSURER B: Specialty National Ins C/US Risk Underwrite P.O. Box 5 7012 INSURER C Oklahoma City, OK 73157 INSURER 0 _ I INSURER E: _ :OVERAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABO F ;RE P R 1 I A D • THS,ANDINC ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT T W CH TI, AT = IS JED OR MAY PERTAIN.THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS.EXCLUSIONS A N.ITR •4S Cl SUCH POLICIES.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. iSK PULR.T EFi tL I IVt YULIt-T tAPIKAI TUN LIMITS _'_ TR TYPE OF INSURANCE POLICY NUMBER p.m/corm(MMI00/YY) DATE(MM/D0I _ GENERAL LIABILITY 3211124875-00 05/21/2000 05/21/2001 EACH OCCURRENCE , 1,000,000 � S- 1,000,000 X COMMERCIAL GENERAL LIABILITY FIRE DAMAGE(Any one ore) i__— 50,000 - I CLAIMS MACE n OCCUR MED EXP(Any one person) Ti 5,000 A PERSONAL a ADV INJURY , $ 1,000,1)00 GENERAL AGGREGATE TS 3,000,00C GENL AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGGi 3,000,000 POLICY JEC'PF OF- I I LOC AUTOMOBILE LIABIL'Y 3XZ124870-00 05/21/2000 05/21/2001 COMBINED SINGLE LIMIT 5 (Ea accident) 1,000,000 X ANY AUTO ---ALL OWNED AUTOS BODILY INJURY S (Per person) SCHEDULED AUTOS -_— -- B HIRED AUTOS BODILY INJURY i (Per accident) NON-OWNED AU"OS Y_�._ PROPERTY DAMAGE (Per accident) AUTO ONLY-EA ACCIDENT -� GARAGE LIABILITY - ANY AUTO OTHER THAN EA ACC i` -_ . AUTO ONLY: AGG 3 -•EXCESS LIABILITY EACH OCCURRENCE -�- --,_ J OCCUR E1 CLAIMS MADE AGGREGATE i !11 DEDUCTIBLE -4--- - -- RETENTION $ -'--- •� A Ui1� WORKERS COMPENSATION ANO 1TORY LIMITS I ILA': f-l- -_T__ EMPLOYERS'LIABILITY E.L.EACH ACCIDENT -,�__y E.L.DISEASE-EA EMPLOYEE; i E.L DISEASE-POLICY LIMIT rS OTHER DESCRIPTION OF OPERATI•DNS/LOCATIONSNEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS iee attached for list of locations. \dditional Insured on General Liability - 'Division of Criminal Justice - Colorado CERTIFICATE HOLDER I I ADDITIONAL INSURED;INSURER LETTER CANCELLATION - SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,THE ISSUING COMPANY WILL ENDEAVOR TO MAIL 10 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LIABILITY Division of Criminal Justice 700 Ki pl 1 ng, Suite 1000 OF ANY KIND UPON THE COMPANY,ITS AGENTS OR RRE,PR�ESEENTATIVES. -- AUTHORIZED REPRESENTATIVE Cex..... - Denver, CO 80215 •� ``�'�c-c.-Er. Greg Moore/HH T ACORD 25-S VW) �� ,lu f 4w 01-05 -.20 2000-1623 IMPORTANT If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed.A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). 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). DISCLAIMER The Certificate of Insurance on the reverse side of this form does not constitute a contract between the issuing insurer(s), authorized representative or producer, and the certificate holder, nor does it affirmatively or negatively amend, extend or alter the coverage afforded by the policies listed thereon. R.UNu 25-S(1/97) Division of Criminal Justice Certificate issued to Division of Criminal Justice 06/20/2000 Ledbetter Insurance Agency, Inc. 01/19/2000 Locations: 1750 6th Avenue , Greeley, Colorado 555 18th Street, Greeley, Colorado 1776 6th Avenue, Greeley, Colorado 1796 6th Avenue , Greeley, Colorado 1786 6th Avenue , Greeley, Colorado 521 17th, Greeley, Colorado 1730 6th Avenue , Greeley, Colorado 1750 6th Avenue , Greeley, Colorado POLICY NUMBER: COMMERCIAL AUTO 3XZ124870-00 CA 20 01 02 99 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED -- LESSOR This endorsement modifies insurance provided under the following: BUSINESS AUTO COVERAGE FORM BUSINESS AUTO PHYSICAL DAMAGE COVERAGE FORM GARAGE COVERAGE FORM MOTOR CARRIER COVERAGE FORM TRUCKERS COVERAGE FORM 1Mth respect to coverage provided by this endorsement, the provisions of the Coverage Form apply unless modified by the endorsement. This endorsement changes the policy effective on the inception date of the policy unless another date is indi- cated below. Endorsement Effective: 5-21.00 Countersigned By: Named Insured: Avalon Correctional Services, Inc. (Authorized Representative) SCHEDULE Insurance Company Specialty National Insurance Company — Policy Number 3X2124870-00 Effective Date 05-21-00 —� Expiration Date 05-21-01 Named Insured PO Box 57012, Oklahoma City, OK Address —� Additiona: Insured (Lessor) State of Colorado Department of Human Services, Alcohol & Drug Abuse Division Address C/o Serasin Diaz, 4055 S. Lowell Blvd., Bldg KA, Denver, CO 80236 Designation or Description of"Leased Autos" All Vehicles ___---- Coverages Limit Of Insurance Liability $ 1,000,000 Each "Accident" Personal Injury Protection (or equivalent no-fault coverage) $ Comprehensive ACTUAL CASH VALUE OR COST OF REPAIR WHICHEVER IS LES3: MINUS: $ For Each Covered "Leased Auto" Collision ACTUAL CASH VALUE OR COST OF REPAIR WHICHEVER IS LESS; MINUS: $ For Each Covered "Leased Auto" Specified Causes of Loss ACTUAL CASH VALUE OR COST OF REPAIR WHICHEVER IS LESS', MINUS: $ For Each Covered "Leased Auto" (If no entry appears above, information required to complete this endorsement will be shown in the DE clay ations as appliu ble to this endorsement.) rA q'1 Copyright, Insurance Services Office, Inc., 1998 Page 1 of 2 t] ENDORSEMENT NO, -- ATTACHED TO AND ENDORSEMENT EFFECTIVE FORMING A DART OF (Standard Time) INSURED AGENCY AND C )DE POLICY NUMBER MO. DAY YR. 12:01 NOON A.M. Avalon Correcticnal Services,Inc. 3ZH124875-00 05 21 00 X 430065 1 I _ THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED -DESIGNATED PERSON CR ORGANIZATION This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE FORM--CRIMINAL JUSTICE SYSTEM OPERATIONS • SCHEDULE Name of Person or Organization: Division of Criminal Justice 700 Kipling, Suite 1000 Denver, CO Ei0215 State Of Coicrado Department of Human Services Alcohol & Drug Abuse ;Division O/O Serasin Diaz 4055 S. Lowell Denver, CO 80236 (If no entry appears above, information required to complete this endors::r..ent will be shown in the Declarations as applicable to this endorsement.) WHO IS AN INSURED (Section II) is amended to include as an insured the person or organization shown 'n the Schedule as an insured but only with respect to liability arising out of Jour operations or premises owned by or rented to you. ALL OTHER TERMS AND CONDITIONS OF THIS POLICY REMAIN UNCHANC; 37 AUTH afigI R1 Sarf fi/E —�' DATE LB 24939a (01/00) Copyright,Insurance Services Office,Inc.,1984 ACCORD .'CERTIFICATE OF LIABILITY- INSURANUL "` MM/own) PRODUCER (405)E40-9090 FAX (405)840-9651 A'IEI ' RMATIO000 IS CER rIFICAI E IS ISSUED AS A MATTER OFIFIFORTvIAT(Ol� _edbe eter InsLrance Agency, Inc. -- ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AMEND, EXTEND OR 1000 N.W. Grand Blvd. ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Oklahoma City, OK 73118 COMPANIES AFFORDING COVERAGE COMPANY American Home/AIG A Attn: Debbie Wooldridge Ext: INSURED COMPANY II‘ I Avalon Community Services, Inc. B 3 Southern Corrections Systems, Inc. COMPANY P.O. 57)12 C Oklahoma City, OK 73157 of COMPANY D COVERAGES ,2, Fr, : +Ciii4Sx.isi ftk '.`a$YA .a;v'," 'aMi.s..e,':v'r . In n w., t , .1il AL..Qw*�_..�,I. . 4:uI gU., D,A THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE PO_ICY PL-RIOD 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. CO TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE :POLICY EXPIRATION LIMITS LTR DATE(MMAJWYY) DATE(MMAD/YY) GENERAL LIABILITY GENERAL AGGREGATE $ COMMERCIAL GENERAL LIABILITY PRODUCTS-COMP/OP ACC $ I CLAIMS MADE OCCUR. PERSONAL&ADV INJUF:Y $ .'w�:._..I OWNER'S&CONTRACTOR'S PROT EACH OCCURRENCE $ FIRE DAMAGE(Any one Crel $ MEDEXP(Any one person) $ AUTOMOBILE LIP BILITY COMBINED SINGLE LIMIT $ ANY AUTO _... ALL OWNED AUTOS BODILY INJURY $ (Per person) SCHEDULE[AUTOS . ' HIRED AUTCS BODILY INJURY $ (Per accident) NON-OWNED AUTOS PROPERTY DAMAGE $ GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $ ANY AUTO OTHER THAN AUTO ONLY. EACH ACCIDENT $ AGGREGATE $ EXCESS LIABILITY EACH OCCURRENCE $ UMBRELLA FORM AGGREGATE $ OTHER THAN UMBRELLA FORM $ WI.SIAI U- 'Cr WORKERS COMPENSATION AND TORY LIMITS FF. EMPLOYERS'LIABILITY EL EACH ACCIDENT $ 1,000,000 A THE PROPRIETOR/ INCL BINDER - WC 03/01/2000 03/01/2001 EL DISEASE-POLICY LIMIT $ 1,000,000 PARTNERS/EXECUTIVE - 1,000,000 CEFICERS ARE' EXCL EL DISEASE-EA EMPLOYEE $ OTHER DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES/SPECIAL ITEMS Villa at Greeley LLC, 1750 6th Ave, Greeley, CO 80631-5814 =EIN # 84-1280281 JI # 4565600 CERT'IFICATE.HOLDER CANCELLATION ,.,: ; _ , • -- _..... ...Y. 't ... ... .. e .- .._ a v ._. .e r_..-». .. -. -X THE DESCRIBED ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE Department of Labor & Employment EXPIRATION DATE THEREOF,THE ISSUING COMPANY WILL ENDEAVOR TO MAIL Division of Worker's Compensation 10 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT. Coverage Enforcement Unit BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LIABILITY 1515 Arapahoe Street Tower 3, Suite 333 OF ANY KIND UPON THE COMPANY,ITS AGENTS OR REPRESENTATIVES. AUTHORIZED REPRESENTATIVEQgtaril _ Denver, CO 80202-2117 C (��zF, Greg Moore/HH ACORD 255(1195)` A'" ©ACORD CORPORATION 198 (j$p��■/,/�++��__ jjQp��(�P� "�sGlf la IC I 'a �1 `�`iiG �F L` 1fr' BILIT r N U;RAIt�10E�t ;'' r ATE(a+ra eDYr A cORL {h,9 ,+t .y� t ^t n •( .94.i��MA1 .,i .I R'y1 99 t1A YxIa.lay "`4 �i ��'9�� ^';^',! ,��1"s- ( �/23/i(,0(I ... r..:.-.. ,...'x"A�.J :i ,',k0.^:.a, l id; ,'''4:,,:,-Y r .-_.- '.. , ,1.,/ .-. -"f PROOLJCER (405)840-9090 FAX (405)840-9691 THIS CERTII-ILA IS IS5Uto AS A MAI I tK UFTiTFO)1MALION-- ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE edbetter Insurance Agency, Inc. HOLDER.THIS CERTIFICATE DOES NOT AMEND, EXTEND OR 1000 N.W. Grand Blvd. ALTER THE COVERAGE AFFORDED BY THE POLICIES-BELOW. _V Oklahoma Ci t:,, OK 73118 COMPANIES AFFORDING COVERAGE COMPANY American Home/AIG Attn: Debbie Wooldridge Ext: A • INSURED COMPANY I (co,I fl(I I. )I!'r� r i r'' r !`t I(' a Avalon Community Services, Inc. B i\I 1 n.�L..' ( hr ' II 1,, i , jj Inc. r I....,; ! I A. Southern Corrections Systems, COMPANY 1 `'` it"A }a ' I II P 0 57012 c 11 ` 1 I{•Oklahoma City, OK 73157 _.. .. .. 4 COMPANY D H, . � _,. �N5K Y. �. :; .,.. . ;�,:3.: �. 1.'i:9, �.e,,,� � i� hr �y<,(K. • . ... ..^. COVERAGES,,,,,:,,,'„,',0-„:4.,', f IA✓r 1i,;5r .r. h:.4i„/1 �i,:,..—il� *„na; ... «,�, �'y 4 4.4i,..AVE1 LL..:' �!.:.... ' t-.i•Ir, l^lw"A1.. ..7f J,71 ,.-a.,,.. �r •.. . aw.r.TO'.CE/3:FJld THAT TH • ,.....,,,,,,...-.4,- ~ 7NlS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIQD 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/%ND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. . CO POLICY NUMBER POLICY EFFECTIVE ;POLICY EXPIRATION' LIMITS LTR: TYPE OF INSURANCE DATE(MMIDO/YY) ' DATE(MM/DO/YY) GENERAL AGGREGATE 3 GENERAL LIABILITY PRODUCTS-COMP/OF'AG3 $ COMMERCIAL GENERAL LIABILITY .... � --- PERSONAL&ADV INJURY $ AO aims MADE OCCUR EACH OCCURRENCE $ OWNER'S S CONTRACTOR'S PROT - - FIRE DAMAGE(Any one fee, $ MED EXP(Any one Per<onl $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT .ANY AUTO ALL OWNED AUTOS BODILY INJURY I (Per Person) SCHEDULED AUTOS HIRED AUTOS BODILY INJURY $ (Per accident) NON-OWNED AUTOS PROPERTY DAMAGE $ • AUTO ONLY-EA ACCIDENT S GARAGE UABILITY OTHER THAN AUTO ONLY: ANY AUTO EACH ACCIDENT ., AGGREGATE 3 EACH OCCURRENCE EXCESS LIABILITY AGGREGATE 'I UMBRELIA FORM OTHER THAN UMBRELLA FORM wL a I AI U- um. I• TORY LIMITS i:R WORKERS COMPENSATION AND EMPLOYERS'LIABILITY EL EACH ACCIDENT $ 1,000,000 A BINDER - WC 03/01/2000 03/01/2001 EL DISEASE-POLICY LIMIT s 1,000,000 THE PROPRIETOR/ INCL ...... ... ..... ... PARTNERSIE:(ECUTWE EL DISEASE-EA EMPLOYE '5 1,000,000 OFFICERS ARE: ' EXCL --I -� OTHER DESCRIPTION OF OPERATIONS/LOCATIONSNEHICLES/SPECIAL ITEMS illa at Greeley LLC, 1750 6th Ave, Greeley, CO 80631-5814 EIN # 84-1280281 I # 4565600 CANCELLATIONi .., -:::,t***':i CERTIFICATE,HOLDER x a«4 ; . ,Y { , ..�.. . . .. I.' «. _-....::.r.,hJ,.,�b:.::u- �y t ,.-,.::4... „c:_.r.:+-,.wx a�:.Lr.?...�s.„Ta...,.-�.'^it�.:j:. .�..�!' 4�.. .. w_ ,, f.a. ._. ._.> s� u SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE Department of Labor & Employment EXPIRATION DATE THEREOF,THE ISSUING COMPANY WILL ENDEAVOR TO MAIL Division of Worker's Compensation 10 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLLER NAMED TO THE LEFT, Cove;"age Enforcement Unit BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LIABILITY 1515 Arapahoe StreetTowe OF ANY KIND UPON THE COMPANY,ITS AGENTS OR REPRESENTATIVES- Denv COST0e 333 80202-2117 AUTHORIZED REPRESENTATIVE envr, O 5~ ,}.•, . Greg Moore/HH ©ACORD CORPORATION 1988 AC ORD'254(1195) 1•r!.t:..w.) ,_;. :,„4{, ; ;# '` ,.tY-:h r r'S"#.x i r j`' „A Hello