HomeMy WebLinkAbout20210218.tiffFREDERICK -FIRESTONE
FIRE PROTECTION
DISTRICT
Leading- Together,
Sergi ;rn� Together
BOARD OF DIRECTORS
Office: 303.833.2742
Fax: 303.833.3736
WWW.FFFD.US
BOARD OF DIRECTORS
OATH OF OFFICE
STATE OF COLORADO
WELD COUNTY
RECEIVED
JAN 1 8 1021
WELD COUNTY
COMMISSIONERS
FREDERICK -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: QI - 11 - aloa.{
OATH ADMI ISTERED BY:
rTh
Clyde A Walb II
Board P esident
AFFIRMED BEFORE NOTARY
STATE OF COLORADO
COUNTY OF WELD
Subscribed and sworn to before me this t l day of
(notary signature)
) ss.
8426 Kosmerl Place, Frederick, Colorado, 80504-5444
P. O. Box 129, Frederick, Colorado, 80530-0129
ERICA L. VASQUEZ
NOTARY PUBLIC
STATE OF COLORADO
NOTARY ID 20174031773
. NtSmission Ex Tee July 28, 2421
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2021-0218
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BO RD OF DIRECTO
NOTICE OF PPOINTMENT
_ T
At a public meeting held January 11, 2021, the Board of Directors of the Frederick -Firestone Fire Protection District appointed the
following eligible elector to fill a vacancy on the Board of Directors pursuant to Section 32-1-905(3), C.R.S.:
Name: Jeffrey Jurgena
Mailing Address: 5183 Ruby Avenue
Firestone, CO 80504
This appointment will expire at the next regular election in May of 2023.
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Clyde A.alb III — Board President
Board of Directors
Frederick -Firestone Fire Protection District
Per C.R.S. § 32-1-905(3): All appointments shall be evidenced by an appropriate entry in the minutes of the meeting, and the board shall cause a notice of appointment to be
delivered to the person so appointed. A duplicate of each notice of appointment, together with the mailing address of the person so appointed, shall be forwarded to the Division of
Local Affairs in the Department of Local Government.
2907404.1
FREDFIR-01
CHATTER
.4CORL7" CERTIFICATE OF LIABILITY INSURANCE
4...-----�
DATE/4/2
1 1 /4/202211
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
T. Charles Wilson Insurance Service
384 Inverness Parkway Suite 170
Englewood, CO 80172
NTACT
=ACT
N :
PHONE FAX
(A/c, No, Ext): (303) 3685757 I(A/C, No):(303) 368-5863
AADDRESS: info@wilsonins.com
INSURER(S) AFFORDING COVERAGE
NAIC N
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
CERTIFICAT
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
LTR
TYPE OF INSURANCE
ADDL
INSD
SUBR
WVD
POLICY NUMBER
POLICY EFF
(MM/DD/YYYYI
POLICY EXP
(MMIDD/YYYYI
LIMITS
COMMERCIAL GENERAL LIABILITY
EACH OCCURRENCE
$
CLAIMS -MADE
OCCUR
DAMAGE TO RENTED
PREMISES (Ea occurrence)
$
MED EXP (Any one person)
$
PERSONAL & ADV INJURY
$
GEN'L
AGGREGATE LIMIT APPLIES
PRO -
POLICY JECT
OTHER:
PER:
LOC
GENERAL AGGREGATE
$
PRODUCTS - COMP/OP AGG
$
$
AUTOMOBILE
_
LIABILITY
ANY AUTO
OWNED
AUTOS ONLY
AUTOS ONLY
SCHEDULED
AUTOS
NON-DINNED
ONLY
COMBINED SINGLE LIMIT
(Ea accident)
$
BODILY INJURY (Per person)
$
BODILY INJURY (Per accident)
$
PROPERTY accidentDAMAGE
$
$
UMBRELLA LIAR
EXCESS LIAB
_
OCCUR
CLAIMS -MADE
EACH OCCURRENCE
$
AGGREGATE
$
DED
I RETENTION $
$
WORKERS COMPENSATION
AND EMPLOYERS' LIABILITY
ANY PROPRIETCR/PARTNER/EXECUTIVE
RZIgiIMEMBER EXCLUDED?
(Mandatory in NH)
If yes, describe under
DESCRIPTION OF OPERATIONS below
Y I N
N / A
I PER
_ STATUTE I ERH
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 I 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
Division of Local Govemment-Special Districts
1313 Sherman St., Rm 521
Denver, CO 80203
I
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
ACORD 25 (2016/03)
O 1988-2015 ACORD CORPORATION. All rights reserved.
The ACORD name and logo are registered marks of ACORD
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