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Certificate of Insurance
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON YOU THE CERTIFICATE HOLDER. THIS
CERTIFICATE IS NOT AN INSURANCE POUCY AND DOES NOT AMEND,EXTEND,OR ALTER TEE COVERAGc AFFORDED BY THE POLICIES LISTED
BELOW. 1.,. I)
This is to Certify that
BUCKLEN EQUIPMENT COMPANY INC Nanie and'" + r+- I
804 N 25TH AVE address of
GREELEY CO 80631 Insured ,,I -, ; MUTUAL TUAL ft ,
. .. M ,
is, at the issue date of this certificate, insured by the Company under the policy(ies) listed below. The insurance afforded by the
listed policy(ies)is subject to all their terms, exclusions and conditions and is not altered by any requirement,term or condition of
any contract or other document with respect to which this certificate may be issued.
.ERT FICATE EXP.DATE
TYPE OF POLICY * ❑ CONTINUOUS POLICY NUMBER LIMIT OF LIABILITY
0 EXTENDED
x❑ POUCY TERM
Coverage Afforded Under WC EMPLOYERS LIABILITY
Law of the Following States:
Bodily Injury By Accident Each
WORKERS 100,000 Accident
COMPENSATION 1-1-96 WC2-1 91-081160-025 COLORADO Bodily Injury By Disease Pollry
500,000 Limit
Bodily Injury By Disease Each
100,000 Person
GENERAL LIABILITY General Aggregate-Other than Prod/Completed Operations
❑ CLAIMS MADE Products/Completed Operations Aggregate
RETRO DATE Bodily Injury and Property Damage Liability Per
Occurrence
Personal and Advertising Injury Per Person/
El OCCURRENCE Organization
Other: Other:
AUTOMOBILE Each Accident-Single Limit-
LIABILITY B.I.and P.D.Combined
▪ OWNED Each Person
ED NON-OWNED Each Accident or Occurrence
• HIRED Each Accident or Occurrence
OTHER
ADDITIONAL COMMENTS
`IF THE CERTIFICATE EXPIRATION DATE IS CONTINUOUS OR EXTENDED TERM.YOU WILL BE NOTIFIED IF COVERAGE IS TERMINATED OR REDUCED
BEFORE THE CERTIFICATE EXPIRATION DATE. HOWEVER,YOU WILL NOT BE NOTIFIED ANNUALLY OF THE CONTINUATION OF COVERAGE.
SPECIAL NOTICE-OHIO: ANY PERSON WHO,WITH INTENT TO DEFRAUD OR KNOWING THAT HE IS FACILITATING A FRAUD AGAINST AN INSURER,
SUBMITS AN APPLICATION OR FILES A CLAIM CONTAINING A FALSE OR DECEPTIVE STATEMENT IS GUILTY OF INSURANCE FRAUD.
NOTICE OF CANCELLATION: (NOT APPLICABLE UNLESS A NUMBER OF DAYS IS Liberty Mutual
ENTERED BELOW.) BEFORE THE STATED EXPIRATION DATE THE COMPANY WILL NOT Insurance Group
CANCEL OR REDUCE THE INSURANCE AFFORDED UNDER THE ABOVE POLICIES UNTIL
UNTIL AT LEAST DAYS NOTICE OF SUCH CANCELLATION HAS BEEN MAILED TO:
4-k. _I5C1.-e-
CERTIFICATE WELD COUNTY COMMISSIONERS AUTHORIZED REPRESENTATIVE
HOLDER GREELEY CO 80631
1-1-95 ENGLEWOOD
DATE ISSUED OFFICE
7 This certificate is executed by LIBERTY MUTUAL INSURANCE GROUP as respects such insurance as is afforded by Those Companies 9501 80
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