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CERTIFICATE OF INSURANCE
American Family Mutual Insurance Company
r. qQ�'pim¢�rican Parkway
V'IEtMXd�h'[ i onsin 53783-0001
Agent's Name and Address C(1 '° `C1^"r:.
Lesa Ringkjob Agency This certificate is issued as a matter of information
115 E Harmony Ste 130 he only and confers no rights upon the Certificate Holder.
Ft. Collins, CO 80525 1995 t 1 1�� ' 3 !U 13' 59
This certificate does not amend, extend or alter the
CI EPAcoverage afforded by the policies listed below.
Insured's Name and Address n r ,-;�
Sierra Vista Contracting Corporation TO T{-'+, C'_.:.--
PO Box 272267
Ft. Collins, CO 80527
COVERAGES
This is to certify that 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.
TYPE OF POLICY POLICY DATE LIMITS OF
INSURANCE NUMBER EFFECTIVE EXPIRATION LIABILITY
(MO,DAY,YR) (MO.DAY.YR) Statutory .xx.........x.
,000
WORKERS COMPENSATION Each Accident $
AND Disease—Each Employee $ ,000
EMPLOYERS LIABILITY+ Disease—Policy Limit $ ,000
GENERAL LIABILITY General Aggregate $1,000,000
[X] Commercial General 05X75516 11-21-95 11-21-96 Products—Completed Operations $1 ,000,000
Liability Aggregate
(occurrence) Personal and Advertising Injury $1,000,000
[ ] Each Occurrence $1 ,000,000
Fire Damage (Any One Fire) $50,000
Medical Expense (Any One Person) $5,000
[ ]
BUSINESSOWNERS LIABILITY ,000
[ ] Commercial General Each Occurrence ++ $
Liability Aggregate ++ $ ,000
AUTOMOBILE LIABILITY
[ ] Owned Autos Bodily Injury — Each Person $ ,000
(Basic Form)
[ ] Owned Autos Bodily Injury — Each Accident $ ,000
(Comprehensive Form)
[ ] Hired Autos[ ] Non—owned Autos Property Damage $ ,000
[ ] Garage Liability C7 Bodily Injury and
Property Damage Combined $ .000
EXCESS LIABILITY
C ] Commercial Umbrella ,000
Each Occurrence/Aggregate $
[ ]
DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES/RESTRICTIONS/SPECIAL ITEMS
+The individual or partners shown as Insureds [ ]Have [ ]Have not
elected to be covered as employees under this policy.
++Products—Completed Operations aggregate is equal to each occurrence
limit and is included in policy aggregate.
CERTIFICATE HOLDER'S NAME AND ADDRESS CANCELATION
County of Weld Should any of the above described policies be canceled
before the expiration date thereof, the undersigned
915 10th Street company will endeavor to mail *( days) written notice
Greeley, CO 80632 to the Certificate Holder named to the left, but failure to
mail such notice shall impose no obligation or liability of
any kind upon the company, its agents or representatives.
* 10 days unless different number of
days shown. ----
DATE ISSUED 11-8-95 AUTHORI' REPRE TATI _
UBL-11781 Ed. 11/90 lr-
I cJL it InA 4524i34
1 i`�10�-' _
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