for company/agency use only - tworivershoa.com · 2016. 6. 21. · 55300 200507b il0017 198511...

I ssued 0 7 - 2 7 - 2 0 1 5INSURANCE COMPANY TAILORED PROTECTION POLICY DECLARATIONS6101 ANACAPRI BLVD., LANSING, MI 48917-3999

E f f e c t i v e 0 6 - 2 1 - 2 0 1 5DC INSURERS-MOUNTAIN LLC3 2 - 0 0 7 4 - 0 0 MKT TERR 086 ( 3 0 3 ) 420-4774 POLICY NUMBER 152332-74423853-15TWO RIVERS VILLAGE HOADBA C / ROBERTSON & MCHETTI

Company POLICY TERM28 2ND ST UNIT 213 B i l l 1 2 : 0 1 a . m . 1 2 : 0 1 a . m .

t o0 6 - 2 1 - 2 0 1 5 0 6 - 2 1 - 2 0 1 6EDWARDS, CO 81632-8137

FOR COMPANY/AGENCY USE ONLY

THE FOLLOWING DIRECTIVES HAVE BEEN ISSUED FOR THIS POLICY:

ATTACHED FORMS MUST BE VIEWED IN MOBIUS APPS SUITE.

59390 201501C 59350 201501D 55405 200807B 55146 200406B 55592 201402 55091 200810F55448 200905 55447 200905 55084 200406B IL0021 200207A 55296 200909A 55637 20140955300 200507B IL0017 198511 55513 201111 55576 201306 59319 200602A

Premium/Commission Recap: $1 ,198 @ 16.0%

B i l l i n g Type: Company B i l l FULL PAY Account 014550716Insured Copy Mai led t o : Insured

T r a i l b a c k Date : 07-27-2015 U s e r - I D : E013563O r i g i n a l E f f e c t i v e Da te : 06-21-2015

Reinsurance Dec Copy: No

3 2 - 0 0 7 4 - 0 0 152332-74423853

DC INSURERS-MOUNTAIN LLC3705 KIPLING ST UNIT 104WHEAT RIDGE, CO 80033

0 7 - 2 7 - 2 0 1 5

( 3 0 3 ) 420-4774

TWO RIVERS VILLAGE HOA 74423853DBA C / ROBERTSON & MCHETTI48X 2V8 V2N28 2ND ST UNIT 213

EDWARDS, CO 81632-8137

$ 1 , 1 9 8 . 0 0$119 .00

$ 1 , 0 7 9 . 0 0

* * * * * * * THIS IS NOT A BILL. * * * * * * *IF ADDITIONAL PREMIUM IS OWED, A BILL WILL BE MAILED SEPARATELY. PLEASEPAY ANY UNPAID BILLS.

Serving Our Policyholders and Agents for More Than 90 Years

Page 1 55039 ( 1 1 - 8 7 )Issued 0 7 - 2 7 - 2 0 1 5

INSURANCE COMPANY TAILORED PROTECTION POLICY DECLARATIONS6101 ANACAPRI BLVD., LANSING, MI 48917-3999

E f f e c t i v e 0 6 - 2 1 - 2 0 1 5DC INSURERS-MOUNTAIN LLC3 2 - 0 0 7 4 - 0 0 MKT TERR 086 ( 3 0 3 ) 420-4774 POLICY NUMBER 152332-74423853-15TWO RIVERS VILLAGE HOADBA C / ROBERTSON & MCHETTI

Company POLICY TERM28 2ND ST UNIT 213 B i l l 1 2 : 0 1 a . m . 1 2 : 0 1 a . m .

t o0 6 - 2 1 - 2 0 1 5 0 6 - 2 1 - 2 0 1 6EDWARDS, CO 81632-8137

COMMON POLICY INFORMATION

BUSINESS DESCRIPTION: Hoa

ENTITY: Assoc ia t ion

THIS POLICY CONSISTS OF THE FOLLOWING COVERAGE PART(S) . PREMIUM

THIS PREMIUM MAY BE SUBJECT TO ADJUSTMENT.

COMMERCIAL GENERAL LIABILITY COVERAGE $ 1 , 1 9 8 . 0 0

TOTAL $ 1 , 1 9 8 . 0 0

PAID I N FULL DISCOUNT $119 .00

TOTAL POLICY PREMIUM I F PAID I N FULL $ 1 , 0 7 9 . 0 0

The Paid i n F u l l Discount does not apply t o f i x e d f e e s , s t a t u t o r y charges or minimum premiums.The Paid i n F u l l Discount i s based on f a v o r a b l e loss exper ience f o r the c o l l e c t i v e group o fpo l i cyho lders who choose t o pay t h e i r premiums i n f u l l d i r e c t l y t o the Company.

FORMS THAT APPLY TO ALL COVERAGE PART SHOWN ABOVE (EXCEPT GARAGE L I A B I L I T Y , DEALER'SBLANKET, COMMERCIAL AUTOMOBILE, I F APPLICABLE)

55003 ( 0 1 - 8 7 )

A M e r i t Ra t ing Plan F a c t o r o f 0 . 9 5 A p p l i e s .

Countersigned By: COMPANY ISSUED

Page 2 55040 ( 1 1 / 8 7 )OWNERS I N S . CO. Issued 0 7 - 2 7 - 2 0 1 5

DC INSURERS-MOUNTAIN LLC Company POLICY NUMBER 152332-74423853-153 2 - 0 0 7 4 - 0 0 MKT TERR 086 B i l l

TWO RIVERS VILLAGE HOA Term 0 6 - 2 1 - 2 0 1 5 t o 0 6 - 2 1 - 2 0 1 6

COMMERCIAL GENERAL LIABILITY COVERAGE

LIMITS OF INSURANCEGenera l Aggregate $ 3 , 0 0 0 , 0 0 0

( O t h e r Than Products-Completed O p e r a t i o n s )Products-Completed Operat ions Aggregate 3 , 0 0 0 , 0 0 0Personal I n j u r y And A d v e r t i s i n g I n j u r y 1 , 0 0 0 , 0 0 0Each Occurrence 1 , 0 0 0 , 0 0 0Assn D i r e c t o r s / O f f i c e r s E r r o r s and Omissions Agg 1 , 0 0 0 , 0 0 0Assn D i r e c t o r s / O f f i c e r s E r r o r s and Omissions Occ 1 , 0 0 0 , 0 0 0

Commercial Genera l L i a b i l i t y P lus Endorsement

Damage t o Premises Rented t o You 300 ,000 Any One Premises( F i r e , L i g h t n i n g , E x p l o s i o n , Smoke o r Water Damage)

Medica l Payments 1 0 , 0 0 0 Any One PersonH i r e d Auto & Non-Owned Auto 1 , 0 0 0 , 0 0 0 Each Occurrence

Expanded Coverage D e t a i l s See Form:Extended W a t e r c r a f tPersonal I n j u r y ExtensionBroadened Supplementary PaymentsBroadened Knowledge Of OccurrenceA d d i t i o n a l Products-Completed Operat ions AggregateB lanke t A d d i t i o n a l Insured - Lessor o f Leased EquipmentB lanke t A d d i t i o n a l Insured - Managers o r Lessors o f PremisesNewly Formed o r Acquired O r g a n i z a t i o n s ExtensionBlanke t Waiver o f Subrogat ion

Twice t h e "Genera l Aggregate L i m i t " , shown above, i s prov ided a t no a d d i t i o n a lcharge f o r each 12 month p e r i o d i n accordance w i t h form 5 5 3 0 0 .

AUDIT TYPE: Non-Audited

FORMS THAT APPLY TO THIS COVERAGE: 59350 ( 0 1 - 1 5 ) 55146 ( 0 6 - 0 4 ) 55592 ( 0 2 - 1 4 )55091 ( 1 0 - 0 8 ) 55448 ( 0 5 - 0 9 ) 55447 ( 0 5 - 0 9 ) 55084 ( 0 6 - 0 4 ) IL0021 ( 0 7 - 0 2 )55296 ( 0 9 - 0 9 ) 55637 ( 0 9 - 1 4 ) 55300 ( 0 7 - 0 5 ) IL0017 ( 1 1 - 8 5 ) 55513 ( 1 1 - 1 1 )55576 ( 0 6 - 1 3 ) 59319 ( 0 2 - 0 6 )

LOCATION OF PREMISES YOU OWN, RENT OR OCCUPY

LOC BLDG001 001 80 Lakeshore DrGypsum, CO 81637-7321

TERRITORY: COUNTY:002 Eagle

PremiumC l a s s i f i c a t i o n Sub l ine Basis Rates Premium

CODE 00501 Prem/Op PremCommercial Genera l L i a b i l i t y P lus I n c I n c I n cPrem/OpEndorsement I n c l u d e d At 7.5% OfThe Premises Operat ion Premium

Page 3 55040 ( 1 1 / 8 7 )Issued 0 7 - 2 7 - 2 0 1 5

INSURANCE COMPANY TAILORED PROTECTION POLICY DECLARATIONS6101 ANACAPRI BLVD., LANSING, MI 48917-3999

E f f e c t i v e 0 6 - 2 1 - 2 0 1 5DC INSURERS-MOUNTAIN LLC3 2 - 0 0 7 4 - 0 0 MKT TERR 086 ( 3 0 3 ) 420-4774 POLICY NUMBER 152332-74423853-15TWO RIVERS VILLAGE HOADBA C / ROBERTSON & MCHETTI

Company POLICY TERM28 2ND ST UNIT 213 B i l l 1 2 : 0 1 a . m . 1 2 : 0 1 a . m .

t o0 6 - 2 1 - 2 0 1 5 0 6 - 2 1 - 2 0 1 6EDWARDS, CO 81632-8137

COMMERCIAL GENERAL LIABILITY COVERAGE

CODE 00811 F l a t Charge113 5 . 8 3 2 $659 .00Assn D i r e c t o r s / O f f i c e r s E r r o r s And P r o f e s s i o n a l

Omissions

CODE 41669 Members Each 1Homeowners &/Or Mobi le Homeowners Prem/Op 113 1 . 1 8 7 $134 .00Assoc ia t ion - No B u i l d i n g s Or Prod/Comp Op 113 . 0 1 5 $ 2 . 0 0Premises Owned Or Leased ExceptFor O f f i c e Purposes.( F o r - P r o f i t )

CODE 48925 Pools1 383 .097 $383 .00Swimming Pools Noc Prem/Op1 8 . 2 2 4 $ 8 . 0 0Prod/Comp Op

TERRORISM - CERTIFIED ACTS SEE FORM 5 9 3 5 0 , 5 5 4 0 5 , 59390 $ 1 2 . 0 0

LOCATION 001 PREMIUM $ 1 , 1 9 8 . 0 0

THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.

THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.

THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.

THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.

THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.

THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.

THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.

THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.

COMMON POLICY CONDITIONS