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Home My WebLink About000279.tiff SAFETY NATIONAL Casualty Corporation a DELPHI company CERTIFICATE OF INSURANCE THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICY LISTED BELOW. NAME AND ADDRESS OF CERTIFICATE HOLDER: State of Colorado, State Department of Insurance Department of Labor and Employment, Div of W C Ins Compliance Unit, Div of WC Self Ins Unit 633 17th Street, Suite 400 Denver, Co 80202-3660 This is to certify that the policy of insurance listed below has been issued to the insured named below and is in force at this time. Notwithstanding any requirement, term or condition of any contract or any other document with respect to which this certificate may be issued or may pertain, the insurance afforded by the policy described herein is subject to all the terms, exclusions and conditions of such policy. Should any of the policy described herein be canceled before expiration date thereof the CORPORATION will endeavor to mail ninety (90) days written notice to the above named certificate holder, but failure to mail such notice shall impose no obligation or liability of any kind upon the CORPORATION. NAME INSURED EMPLOYER: WELD COUNTY, COLORADO ADDRESS: P.O. BOX 758,GREELEY, CO 80632 POLICY NUMBER: SP 4041255 TYPE OF INSURANCE: Specific Excess Workers'Compensation and Employers'Liability Insurance • LOCATION(S): COLORADO POLICY LIABILITY PERIOD: December 31,2009 through December 31,2011 POLICY PAYROLL REPORTING PERIOD: December 31, 2010 through December 31, 2011 Self-Insured Retention Per Occurrence $600,000 Maximum Limit of Indemnity Per Occurrence Statutory Employers Liability Maximum Limit of Indemnity Per Occurrence $1,000,000 SAFETY NATIONAL CASUALTY CORPORATION • By: Gene R. Maier, Senior Vice President of Workers' Compensation Underwriting Date: December 21, 2010 1832 Schuetz Road St. Louis MO 63146-3540 314-995-5300 fax 314-995-3843 e,00O2-7 XWC 0003 00 1206 ENDORSEMENT COLORADO NOTICE ENDORSEMENT In consideration of the payment of premium and adherence by both parties to the terms of this Agreement, it is hereby understood and agreed as follows: NOTICE OF CANCELLATION If either the EMPLOYER or the CORPORATION intends to cancel this Agreement, ninety (90) days written notice must be given to the Colorado Division of Workers' Compensation, Self- Insurance Coverage Enforcement Unit, 633 17th Street, Suite 400, Denver, CO 80202-3660. All other terms, conditions,agreements and stipulations remain unchanged. Attached to and forming a part of Excess Workers' Compensation and Employers' Liability Insurance Agreement No. SP 4041255, issued by SAFETY NATIONAL CASUALTY CORPORATION of St. Louis, Missouri to WELD COUNTY, COLORADO, dated December 31,2009. SAFETY NATIONAL CASUALTY CORPORATION President Secretary • Ann Coriano TRAVELERS J 6060$Willow Dr GREENWOOD VILLAGE,CO 80111 November 17,2010 Phone:(720)200-8409 Fax:(720)-200-8398 Email:ACORIANO@travelers.com Julie Ann Vierra GALLAGHER\A J\RMS(011E558) 6399 S FIDDLERS GREEN CIR STE 200 GREENWOOD VILLAGE,CO 80111 I I This is an Agency Billed Policy. • This is the Renewal for: WELD COUNTY,COLORADO P.O.BOX 758 GREELEY,CO 80632 Bond Number: 100729968 Type of Bond: SIWC Obligee Name: COLORADO DEPARTMENT OF LABOR AND EMPLOYMENT/DIVISION OF WORKER'COMPENSATION Obligee Address: 633 17TH STREET#201 Obligee City, State&Zip: DENVER,CO 80202-3660 USA Transaction Effective Date: December 31,2010 Premium Effective Date: December 31,2010 Premium Expiry Date: December 31,2011 Bond Limit: $2,365,085.00 • Bond Premium: $22,705.00 Commission-Percentage: 15% Special Commission: $0.00 Countersignature Branch: Countersignature Commission: $0.00 State Tax: $0.00 State Surcharge: $0.00 TOTAL PREMIUM: $22,705.00 Continents: Thank you for placing your business with us. Producer Name: BARNES,ROBERT F 54123 (9/96)Premium Evidence Colorado Counties Casualty and Property Pool '. Excess Liability — Insurance Co. of the State of Pennsylvania (Claims Made Form) Carrier: Insurance Company of the State of Pennsylvania Policy Number: 6907962 Policy Period: January 1, 2010 to January 1, 2011 Limits: Amounts Coverages $ 10,000,000 Auto Liability, Each Occurrence $ 10,000 Auto Medical Payments. Each Person $ 10,000,000 Personal Injury, Property Damage(Includes Law Enforcement and EMTs) $ 10,000 Premises Medial Payments, Each Person $ 1,000,000 Sewer Backup $ 10,000,000 Public Officials Errors and Omissions $ 1.0,000,000 Employee Benefit Liability Aggregate Limits of Coverage(Apply Separately to CAPP and for each Participating Member County(PMC)) Amounts Coverages $ 10,000,000 In any One Policy Year, Personal Injury, Property Damage $ 10,000,000 In any One Policy Year, Products/Completed Operations $ 10,000,000 In any One Policy Year, Public Officials Liability Errors and Omissions $ 10,000,000 In any One Policy Year, Employee Benefit Liability Self Insured Amounts Coverages Retention (SIR): $ 250,000 Each Occurrence or Wrongful Act(Includes Defense Costs) $ 6,000,000 In any One Policy Year. This aggregate does not include any amounts payable by a PMC for any Occurrence or Wrongful Act as outlined in such County's Agreement for Partially Self-Funded Program issued by CAPP as follows: • SIR is not eroded by the first$75,000 of loss and loss expense for Summit County • SIR is not eroded by the first$125,000 of loss and loss expense for Eagle, Pueblo, and Weld Counties • SIR aggregate is also not eroded by the loss and loss expense for$10,000 ETR deductible loses 7 2010 CAPP Excess Llabllity Summary-Page 1 Colorado Counties Casualty and Property Pool . Excess Property — Lexington Carrier: Lexington Insurance Company (Non-Admitted Carrier) Policy Number: 020412751 Policy Period: January 1, 2010 to January 1, 2012 Named Insured: Colorado Counties Casualty and Property Pool, any official, trustee or employee of the Named Insured while acting within the scope of his duties as such, and any person,organization, trustee or estate to whom the Named Insured is obligated by virtue of written contract or agreement to provide insurance such as is offered by this Insurance, but only in respect to operations by or on behalf of the Named Insured Covered Property: Real &Personal Property,Automobile Physical Damage,and Equipment Breakdown and as per policy form Covered Locations: Refer to Statement of Values • Policy Limits: Amounts Coverages $ 100,000,000 Per occurrence subject to following sublinits Sublimits(other than Equipment Breakdown): ' $25,000,000 In the Aggregate for any one policy year of Earthquake $ 5,000,000 In the Aggregate for any one policy year for Flood loss in Zones A,AO,AE,AN,Al-30,A99, AR $ 50,000,000 In the Aggregate for any one policy year for all Other Flood Combined $ 10,000,000 Newly acquired property, per location are to be reported to the Company within 90 days of acquisition $ 5,000,000 Builders'Risk, renovations, repairs made by the Insured at any location (including new locations with total contract cost under $5,000,000) within the territorial limits of the policy,any one • occurrence $ 1,000,000 Builder's Risk Soft Costs/Additional Expenses; $500,000 any unscheduled location,any one occurrence $ 50,000 Personal Property of Others while on the Insured's property $ 1,000,000 Miscellaneous Unnamed Locations $ 1,000,000 Errors and Omissions Sublimits are part of and not in addition to the Policy Lind o(Liability. These Sublimes do not increase the Policy Limit of liability or any other Sub/init. All Subunits are Per Occurrence unless otherwise Indicated 3 2010 CAPP Excess Property Summary-Page 1 Colorado Counties Casualty and Property Pool Excess Property - Lexington (Continued) Sublimits(other than Equipment Breakdown) (Cont'd): $ 10,000,000 Ordinance Deficiency $ 10,000,000 Extra Expense—No monthly limitation based on period of restoration as defined in the policy $ 1,000,000 Property In Transit $ 25,000 In the Aggregate Pollution Clean Up and Removal, each County listed as a Named Insured $ 25,000 Mold/Fungus Exclusion with exception Endorsement Equipment Breakdown Limits: Amounts Coverages $ 100,000,000 Per Accident(as defined in policy) Sublimits: $ 1,000,000 Extra Expense $ 5,000,000 Builder's Risk $ 1,000,000 Expediting Expense $ 1,000,000 Hazardous Substances $ 1,000,000 Spoilage(includes Ammonia Contamination) Included Water Damage $ 500,000 Data Restoration $ 2,500,000 Ordinance Deficiency Excluded Business Income $ 5,000,000 Newly Acquired Locations—90 Day Reporting Deductible Amounts Coverages $ 150,000 Per Occurrence except $ 5,000 Equipment Breakdown/ Per Accident Covered Perils: Direct Physical Loss except where specifically excluded Manuscript Property Form will be amended to include the items noted above as well as adding wording for errors and omission, miscellaneous unnamed locations, etc. Coinsurance: None 4 2010 CAPP Exccess Property Summary-Page 2 Hello