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Home My WebLink About20221604.tiffBOARD OF DIRECTORS OATH OF OFFICE STATE OF COLORADO WELD_ COUNTY/COUNTIES FREDERCICK-FIRESTONE FIRE PROTECTION DISTRICT I, DAVID W. STOUT , do affirm* that I will support the Constitution of the United States, the Constitution of the State of Colorado, and the laws of the State of Colorado, and will faithfully perform the duties of the office of Director, upon which I am about to enter, to the best of my ability. Date: 6/,Z3/.20 2Z [DAVID W. STOUT] ADMINISTERED BY: By: Name Title SUMMER D. CAMPOS NOTARY PUBLIC STATE OF COLORADO NOTARY ID 20214002416 MY COMMISSION EXPIRES 01/19/2025 8426 Kosmerl Place, Fredrick, Colorado, 80504-5444 CorAl-kun.Co-t;onS 6/2-0 /22 2022-1604 SDOoyd ACORLPn FREDFIR-01 CERTIFICATE OF LIABILITY INSURANCE JELLIOTT DATE(MM/DD/YYYY) 5/17/2022 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must have ADDITIONAL INSURED provisions or be endorsed. 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). PRODUCER TCW Risk Management 384 Inverness Parkway Suite 170 Englewood, CO 80112 CONTACT NAME: au: (303) 368-5757 (A/c, so):(303) Rini, FAX 303 368�i863 nooliEss: tcwinfo@wilsonins.com INSURER(S) AFFORDING COVERAGE NAIC A INSURER A: RLI Insurance Company INSURED Frederick Firestone Fire Protection District PO BOX 129 Frederick, CO 80530 INSURER B : INSURER C: INSURER D : INSURER E : INSURER F : COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE 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 POLIC ES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCE LTR ADDL SUBR INSD WVD POLICY NUMBER POLICY EFF (MM/DD/YYYYI POLICY EXP (MM/DD/YYYYI LIMITS COMMERCIAL GENERAL LIABILITY CLAIMS -MADE ❑ OCCUR EACH OCCURRENCE $ DAMAGE TO RENTED PREMISES (Ea occurrence) $ MED EXP (Any one person) $ PERSONAL & ADV INJURY $ GENERAL AGGREGATE $ GEM_ AGGREGATE LIMIT APPLIES PER: POLICY Tai LOC OTHER: PRODUCTS - COMP/OP AGG $ $ AUTOMOBILE _ LIABILITY ANY AUTO OWNED AUTEO�S ONLY AUTOS ONLY SCHEDULED AUTOpS AUOTNOS ONLY COMBINED SINGLE LIMIT (Ea accident) $ BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ (PerOaadiRdentDAMAGE $ $ _ UMBRELLA LIAB EXCESS LIAB OCCUR CLAIMS -MADE EACH OCCURRENCE $ AGGREGATE $ DED I I RETENTIONS $ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y/ N ANFICCPROR�PRIIETgOREXCLUDED PROPRIETOR/PARTNER/EXECUTIVE ❑ gill story t NH) If yes, describe under DESCRIPTION OF OPERATIONS below N / A I STATUTE I I NH E.L. EACH ACCIDENT $ E.L. DISEASE - EA EMPLOYEE $ E.L. DISEASE - POLICY LIMIT $ A 3 Year Bond LSM0572052 6/1/2020 6/1/2023 Amount 25,000 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) Public Official Position Schedule Bond 1 Treasurer @ $5,000 4 Board Members @$5,000 each CERTIFICATE HOLDER CANCELLATION Colorado Department of Local Affairs P SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Division of Local Government -Special Districts 1313 Sherman St., Rm 521 AUTHORIZED REPRESENTATIVE Denver, CO 80203 1 ,62- Stal- ACORD 25 (2016/03) © 1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD BOARD OF DIRECTORS OATH OF OFFICE STATE OF COLORADO WELD_ COUNTY/COUNTIES FREDERCICK-FIRESTONE FIRE PROTECTION DISTRICT I, JEFFREY JURGENA, do affirm* that I will support the Constitution of the United States, the Constitution of the State of Colorado, and the laws of the State of Colorado, and will faithfully perform the duties of the office of Director, upon which I am about to enter, to the best of my ability. Date: 6723%Z o SI [JEFJURG, N ] ADMINISTERED BY: By: �A�g"t3ed Name -704-,ey /"//L Title SUMMER D. CAMPOS NOTARY PUBLIC STATE OF COLORADO NOTARY ID 20214002416 MY COMMISSION EXPIRES 01/19/2025 8426 Kosmerl Place, Fredrick, Colorado, 80504-5444 ,41(:2O� O' FREDFIR-01 JELLIOTT CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDD/YYYY) THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must have ADDITIONAL INSURED provisions or be endorsed. 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). PRODUCER TCW Risk Management 384 Invemess Parkway Suite 170 Englewood, CO 80112 CONTACT PHONE Fax (ac, No, Eat): (303) 368-5757 (ac, No):(303) 368-5863 AE-MAILSS: tcwinfo@wilsonins.com DD INSURERS) AFFORDING COVERAGE NAIC # INSURER : RLI Insurance Company INSURED Frederick Firestone Fire Protection District PO Box 129 Frederick, CO 80530 INSURER B INSURERC: INSURER D INSURER E : INSURER F : VERAGES • • -- .. - . ---- ...vr.ru.r, THIS IS TO CERTIFY THAT THE 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 POLIC ES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. LTR TYPE OF INSURANCE ADDL SUBR INSD yV1ID POLICY NUMBER (MM/DDY/YYYYI EFF IMM/DD) LIMITS COMMERCIAL GENERAL LIABWTY CLAIMS -MADE OCCUR EACH OCCURRENCE $ PREMIS SO(Ea oar ence) $ MED EXP (Any one person) S PERSONAL 8 ADV INJURY $ GEN1 AGGREGATE LIMIT APPLIES PER: POLICY jE8f LOC OTHER: GENERAL AGGREGATE $ PRODUCTS - COMP/OP AGG $ $ AUTOMOBILE LIABILITY - --ANY AUTO OWNED _ AUTOS ONLY All1 - & ONLY SCHEDULED AUTOS - gUOTNOS ONL� COMBINED SINGLE LIMIT (Ea aaidentl $ BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ (Pg a litAMAGE $ $ - UMBRELLA LIAB EXCESS LIAB OCCUR CLAIMS -MADE EACH OCCURRENCE $ AGGREGATE $ DED I I RETENTION$ $ WORKERS COMPENSATION ANY EMPLOYERS' LIABILITY Y / N ANY PROPRIETOR/PARTNER/EXECUTIVE 8,,,,,,,„„„„,,,,,5,0„ EXCLUDED? If yes, desuibe under DESCRIPTION OF OPERATIONS below N / A - I STATUTE I I Pr E.L. EACH ACCIDENT $ E.L. DISEASE - EA EMPLOYEE $ E.L. DISEASE - POLICY LIMIT $ A 3 Year Bond LSM0572052 6/1/2020 6/1/2023 Amount 25,000 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) Public Official Position Schedule Bond 1 Treasurer @ $5,000 4 Board Members @ $5,000 each ERTIFICATE HOLDER CANCELLATION Colorado Department of Local Affairs Division of Local Government -Special Districts 1313 Sherman St., Rm 521 Denver, CO 80203 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE "a2- Z.. 21.(� ACORD 25 (2016103) © 1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD Hello