HomeMy WebLinkAbout970405.tiff19970109/1455282 /P267 /001
CERTIFICATE OF INSURANCE
issued by the
COLORADO COMPENSATION INSURANCE AUTHORITY
720 South Colorado Blvd, Denver, Colorado 80222, (303) 782-4000
MAIL TO:
WELD COUNTY SOCIAL SERVICES
315 N 11TH AVE
GREELEY CO 80631
TO WHOM IT MAY CONCERN:
CERTIFICATE HOLDER:
WELD COUNTY SOCIAL SERVICES
315 N 11TH AVE
GREELEY CO 80631
This is to certify that this company has issued a Standard Workers' Compensation and Employers'
LiabiLty Policy as described below covering the liability imposed Upon subject employers by the
Workers' Compensation Act of Colorado, said policy being in good standing as of this date.
145328-2 0111011997
POLICY NUMBER:
POLICY PERIOD: 07/01/199
INSURED: ALTERNATIVE HOMES FOR
YOUTH
9201''W 44TH AVE
WHEATRIDGE
ORIGINAL EFFECTIVE DATE: 01/27/1983
IMPORTANT;
TO 07/01/1997
TH
17
E COVERAGE DESCRIBED ABOVE IS IN EFFECT AS OF THE ISSUE DATE OF THIS CERTIFICATE
IS SUBJECT TO CHANGE AT ANY TIME IN THE FUTURE.
All policies are subject to the following provision of the WorkersCompensation Act with respect to
cancellation;
The issuance Of this certificate of insurance is subject to section 8-44-110 G.R.S. which requires that a
thirty (30) day notice of cancellationbe given unless cancellation is based on fraud, material
misrepresentation, nonpayment of premium or any other reason approved by the Commissioner of
Insurance; in such instances, CCIA will provide a ten day notice of cancellation.
Alteration of this document is a criminal offense pursuant to Colorado Criminal Code 18-5-103: "A
person commits second degree forgery, if, with intent to defraud, he falsely makes, completes, alters,
or utters a written instrument which €s or purports to be, Or Which is calculated to become or to
represent if completed: . . . a commercial instrument.
Holders of this certificate may contact our Customer Service Department at 782-4000 fr. vorifi, rnvpranp
for the working classification listed on the back of this certificate.
(—SEE BACK OF CERTIFICATE FOR CLASS COVERAGE AND OWNERSHIP COVERAGE 970405
oi' 7I,4.ARLIsc C.A.U. REP II (505) 782-4000
v9)oio9Nss282 020 /001
BUSINESS LOCATION: -ALTERNATIVE HONES FOR VOUTH
-
CLASSIFICATION -OF OPERATIONCLASS DESCRIPTION
O 8810'95 CLERICAL OFFICE -EMPLOYEES HOC
-Coverege -. effe:07/01/1996 exp: -07/01/1997
08833.05 HOSPITAL: PROFESSIONAL EMPLOYEES
Coverage - off- 01/01/1994 expo 07/01!1!!97-. rating type
O 8868.05 COLLEGE: PROFESSIONAL EMPLOYEES-i.CLERICAL
Coverage--offi. 07/01/1994 .amp:- 07/01/1997 rating -type
UPDATED 7/94 P26702
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