HomeMy WebLinkAbout2021 Oath & Notice - Ted BristolCrime Certificate Holder Declaration
Master Coverage Document Number: Insurer:
Certificate Number: POL-0005936 Coverage Period: 1/1/2021 to EOD 12/31/2021
Named Member:Broker of Record:
Crown Mountain Park and Recreation District T. Charles Wilson Insurance Service
20 Eagle County Dr., Suite F 384 Inverness Parkway
El Jebel, CO 81632 Suite 170
Englewood, CO 80112
Covered ERISA Plan: Covered Designated Agent(s):
Coverage Limits:
Public Employee Dishonesty Coverage:$50,000
Limit is Per Loss
Faithful Performance of Duty
Officers, Directors, and Trustees
Welfare and Pension Plan ERISA Compliance if Covered Plan is shown
Volunteer Workers as Employees
Forgery or Alteration Coverage:$50,000
Theft, Disappearance, and Destruction Coverage:$50,000
Inside Premises
Outside Premises
Computer and Funds Transfer Fraud Coverage:$50,000
Debit, Credit or Charge Card Forgery Coverage:$50,000
Money Orders and Counterfeit Paper Currency Coverage:$50,000
Fraudulent Impersonation Coverage:$50,000
Crime Deductible:$250
Fraudulent Impersonation Deductible: 20% of Fraudulent Impersonation Limit
Contribution: $434
Policy Forms:
Government Crime Policy (Discovery Form)
This Certificate Holder Declaration is made and is mutually accepted by the CSD Pool and the Named Member subject to all
terms which are made a part of the Master Crime Policy. This Certificate represents only a brief summary of coverages. Please
refer to the Master Policy Document for actual coverage, terms, conditions, and exclusions.
Countersigned by:
Authorized Representative
