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HomeMy WebLinkAboutInsurance Certificate: Knife River Materials ACC>Ra CERTIFICATE OF LIABILITY INSURANCE °AM 1M412012 2012 " 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(les) must 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 CONTACT Marsh USA Inc. NAME: UVC, No. Pink HONE ac No : 333 South 7th Street Suite 1600 P Minneapolis, MN 55402.2400 E-MAIL Ann: contmct.reviewC$SOmarsh.tom ADDRESS: INSURERS AFFORDING COVERAGE NAIC t J43750-LTM-GAWX-13-14 2010 2037 2048 AI Y INSURER A: Liberty Mutual Fire Ins Cc 23035 INSURED LTM, INCORPORATED INSURER B: Associated Electric & Gas Ins Services Ltd 3190004 DBA KNIFE RIVER MATERIALS INSURER C: Liberty Mutual Insurance Company 23043 PO BOX 1145 INSUflEfl D: MEDFORD, OR 97501 .SURER E2: INSURER F : COVERAGES CERTIFICATE NUMBER: CHI-004334737-OB 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 POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSfl ADDLSUBR LT TYPE OF INSURANCE J POLICY NUMBER MMIDD/YYYY MWDD/YYYY LIMITS R A GENERAL LIABILITY TB2641005097-043 01/0112013 0110112014 EACH OCCURRENCE $ 2,000.000 X DAMA E R NTEO 500.000 COMMERCIAL GENERAL LIABILITY PREMISES Ea occurrence $ CLAIM&MJ DE M OCCUR MED EXP (Anyone person) $ 10,000 X PER PROJECT AGGREGATE PERSONAL & ADV INJURY $ 2000.000 GENERAL AGGREGATE $ 4.000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 4,OW,000 POLICY PRO- LOC $ A AUTOMOBILE LIABILITY AS2641005097-053 0110112013 01/0112014 COMBINED SINGLE LIMIT 2,000,000 So acciden X ANY AUTO BODILY INJURY (Per Person) $ ALL OWNED SCHEDULED - AUTOS AUTOS BODILY INJURY (Per accident) $ X X NON-OWNED PROPERTY DAMAGE $ HIREDAUTOS AUTOS Per accident B UMBRELLA LIAB OCCUR XL5063402P 0110112013 01101/2014 EACH OCCURRENCE $ 5.000,000 X EXCESS LIAB CLAIMS-MADE AGGREGATE $ 5,000,000 DEC RETENTION $ C WORKERS COMPENSATION WC7-641-005097-023(Guar. Cost) 01101/2013 01101/2014 X I In WCSTATU- OR TH- AND EMPLOYERS' LIABILITY N/A WA7-64D-005097-013(ADS) 01/01/2013 01/0112014 E.L. EACH ACCIDENT $ 1'000'000 C ANY PROPRIETOR/PARTNERIEXECUTIVE YIN C (Mandatory In NH) ) EXCLUDED? WC7-641-005097-033 (WI) 0110112013 01/0112014 E.L. DISEASE - EA EMPLOYE $ 1,000,000 OFFIllEWMErl If yes, aescrihe under 'Includes 'Stop-Gap" 1,000,000 DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT $ DESCRIPTION OF OPERATIONS/ LOCATIONS /VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is reaulrad) Re: All Operations City of Ashland islare included as additional insured per the attached CG 2010 and CG 2037 Endorsements and does not include professional liability coverage. Blanket Additional Insured far Automobile Liability is included per attached designated Insured Endorsement CA 20 4B. Excess liability, applies to general lability, products and compleled operations, automobile liability, and empbyers liability. i Y RcC0- iiL CERTIFICATE HOLDER CANCELLATION City of Ashland SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Attn: Koo Olsen THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 90 N. Mountain ACCORDANCE WITH THE POLICY PROVISIONS. Ashland, OR 97520 _ AUTHORIZED REPRESENTATIVE of Marsh USA Inc. Mannish! Mukherjee _,TAauoo>LL -e ®1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25 (2010/05) The ACORD name and logo are registered marks of ACORD Policy Number. AS2-641-005097-053 Issued By: Liberty Mutual Fire Insarar_ce Co. THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. NOTICE OF CANCELLATION TO THIRD PARTIES This endorsement modifies insurance provided under the following: BUSINESS AUTO COVERAGE PART MOTOR CARRIER COVERAGE PART GARAGE COVERAGE PART TRUCKERS COVERAGE PART EXCESS AUTOMOBILE LIABILITY INDEMNITY COVERAGE PART SELF-INSURED TRUCKER EXCESS LIABILITY COVERAGE PART COMMERCIAL GENERAL LIABILITY COVERAGE PART EXCESS COMMERCIAL GENERAL LIABILITY COVERAGE PART PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE PART LIQUOR LIABILITY COVERAGE PART Schedule Name of Other Person(s)! Email Address or mailing Number Organization(s): address: Days Notice: Per schedule on file with the I 90 company I 1 r i A. If we cancel this policy for any reason other than nonpayment of premium, we will notify the persons or organizations shown in the Schedule above. We will send notice to the email or mailing address listed above at least 10 days, or the numnor of days listed above. if any, before the cancellation becomes effective. In no event does the notice to the third party exceed the notice to the first named insured. B. This advance notification of a pending cancellation of coverage is intended as a courtesy only. Our failure to provide such advance notification will not extend the policy cancellation date nor negate cancellation of the policy. All other terms and conditions of this policy remain unchanged. LIM 99 01 0511 Cc> 2011, Liberty Mutual Group of Companies. All rights reserved. Page 1 of 1 includes copyrighted material of Insurance Services Office, Inc. with its permission. THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. DESIGNATED INSURED This endorsement modifies insurance provided under the following: BUSINESS AUTO COVERAGE FORM GARAGE COVERAGE FORM MOTOR CARRIER COVERAGE FORM TRUCKERS COVERAGE FORM With respect to coverage provided by this endorsement, the provisinns of the Coverage Form apply unless modi- fled by this endorsement. This endorsement identifies person(s) or organization(s) who are "insureds" under the Who Is An Insured Provi- sion of the Coverage Form. This endorsement does not alter coverage provided in the Coverage Form. SCHEDULE Name of Person(s) or Organization(s): . Any person or organization for whom you have agreed in writing to add as an additional insured, bat only to coverage and minimum limit of insurance required by the writtenagrcement, and in no event to exceed either the scope of coverage or the limits of insurance provided in this policy. This policy will be primary and non-contributory to any like insurance available to the person or organization noted above. (If no entry appears above, information required to complete this endorsement will be shown in the Declarations as applicable to the endorsement.) Each person or organization shown in the Schedule is an "insured" for Liability Coverage, but only to the extent that person or organization qualifies as an "insured" ender the Who Is An Insured Provision contained in Section 11 of the Coverage Form. Policy No: AS2-641-005097-.053 Issued By: Liberty Mutual Fire Tr.susarce Co. Effective Date: 01/01/2013 Expiration Date: 01 /01/2014 Sales Office: 0465 CA 20 48 02 99 Copyright, Insurance Services Office, Inc., 199£3 Page l of 1 1 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - OWNERS, LESSEES OR CONTRACTORS - SCHEDULED PERSON OR ORGANIZATION This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Name of Person or Organization: Any person or organization for whom you have agreed in writing prior to a loss to provide liability insurance (If no entry appears above, information required to complete this endorsement will be shown in the Declarations as applicable to this endorsement.) A. Section 1I - Who Is An Insured is amended to (1) All work, including materials, parts or Include as an insured the person or organization equipment furnished in connection with shown in the Schedule, but only with respect to such work. on the project (other than liability arising out of your ongoing operations per- service, maintenance or repairs) to be formed for that insured. . performed by or on behalf of the addi- B. With respect to the insurance afforded to these tional insured(s) at the site of the cov- additional Insureds, the following exclusion is ered operations has been completed; added or 2. Exclusions This insurance does not apply to "bodily inju- ry" or "property damage" occurring after: CG 20 10 10' 01 9 ISO Properties, Inc., 2000 Page 1 of 2 (2) That portion of "your work" out of which the injury or damage arises has been put to its intended use by any person or organization other than another con- tractor or subcontractor engaged in performing operations for a principal as a part of the same project. This endorsement is executed by the LIBERTY MUTUAL F;RE INSURANCE COMPANY - Pramit:m 5 Effective Date Explrelion Date for attachment to Pa4uy No. TB&841.005097-043 Audit Basis Issued To Coo.mtersigned by Authc-cedrepresenlative Issued Sales Office and No. End. Beriat No. Page 2 of 2 l?) ISO Properties, Inc., 2000 CG 20 10 10 01 ❑ POLICY NUMBER: TB2-641-00509 7-043 COMMERCIAL GENERAL LIABILITY CG 20 37 07 04 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - OWNERS, LESSEES OR CONTRACTORS - COMPLETED OPERATIONS This endorsement modes insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART Section II - Who Is An Insured is amended to include as an additional insured the person(s) or organization(s) shown in the Schedule, but only with respect to liability for "bodily injury" or "property dam- age" caused, in whole or in part, by "your work" at the location designated and described in the sched- ule of this endorsement performed for that additional insured and included in the "products-completed operations hazard". SCHEDULE Name Of Additional Insured Person(s) Or Organization(s): Location And Description Of Completed Operati ons Any person or organization for whom you have agreed in writing prior to loss to provide liability insurance Information required to complete this Schedule, if not shown above, vw1I be shown in the Declarations. CG 20 37 07 04 © ISO Properties. Inc., 2004 Page 1 of 1 Policy Number TB2-641-005097-043 Issued by LIBERTY &1L7TUAL FIRE INSU.R.4NCE COMP_`,NY THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. NOTICE OF CANCELLATION TO THIRD PARTIES This endorsement modifies insurance provided under the following: BUSINESS AUTO COVERAGE PART MOTOR CARRIER COVERAGE PART GARAGE COVERAGE PART TRUCKERS COVERAGE PART .EXCESS AUTOMOBILE LIABILITY INDEMNITY COVERAGE PART SELF-INSURED TRUCKER EXCESS LIABILITY COVERAGE PART COMMERCIAL GENERAL LIABILITY COVERAGE PART EXCESS COMMERCIAL GENERAL LIABILITY COVERAGE PART PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE PART LIQUOR LIABILITY COVERAGE PART COMMERCIAL LIABILITY- UMBRELLA COVERAGE FORM Schedulo I Name of Other Person(s)/ Email Address or mailing address: Number Days Notice: Or an'zation s : Per Schedule on file with 90 the Company l A. If we cancel this policy for any reason other than nonpayment of premium, we will notify the persons or organizations shown in the Schedule above. We will send notice to the email or mailing address listed above at least 10 days, or the number of days listed above, if any, before the cancellation becomes effective. In no event does the notice to the third party exceed the notice to the first named insured. B. This advance notification of a pending cancellation of coverage is intended as a courtesy only. Our failure to provide such advance notification will not extend the policy cancellation date nor negate cancellation of the policy; All other terms and conditions of this policy remain unchanged. LIM 9901 0511 ce~- 2011 Liberty Mutual Group of Companies. All rights reserved. Page 1 of 1 Includes copyrighted material of Insurance Services Office. Inc., with its permission. NOTICE OF CANCELLATION TO THIRD PARTIES A. If we cancel this policy for any reason other than nonpayment of premium, we will notify the persons or organizations shown in the Schedule below. We will send notice to the email or mailing address listed below at least 10 days, or the number of days listed below, If any, before cancellation becomes effecUve. In no event does the notice to the third party exceed the notice to the first named Insured. 8. This advance notification of a pending cancellation of coverage Is Intended as a courtesy only. Our failure to provide such advance notification will not extend the policy cancellation date nor negate cancellation of the policy. Schedule Name of Other Person(s)1 Email Address or mailing address: Number Days Notice: Organization (s): Per schedule on file with the 90 company All other terms and conditions of this policy remain unchanged. Issued by Liberty Insurance Corporation 21814 For attarhmerrt to Policy No. WA7-640-005097.013 Effective Date Premium $ Issued to Centennial Energy Holdings, Inc. VIM 9018 0611 t~ 2011, Liberty Mutual Group. All Rights Reserved. Page 1 of 1 Ed. 0610112011 NOTICE OF CANCELLATION TO THIRD PARTIES A. If.we cancel this policy for any reason other than nonpayment of premium, we will notify the parsons or organizations shorn in the Schedule below- We will send notice to the email or malting address listed below at least 10 days, or the number of days listed below, if any, before cancellation becomes effective. In no event does the notice to the third parry exceed the notice to the first named insured. B. This advance notification of a pending cancellation of coverage is intended as a courtesy only. Our failure to provide such advance notification will not extend the policy cancellation date nor negate cancellation of the policy. Schedule Name of Other Person(s) I Email Address or mailing address: Number Days Notice: Organization(s): Per schedule or file with the 90 cornpany All other torms and conditions of this policy remain unchanged. Issued by Licedy Insurance Corporaticn 21814 For attachment to PoBcy No. WC7-641-0097.023 Effective Data Premium $ Issued ;o Po1DU Resources Group; Inc. WM 90 18 0611 2011, Liberty Mutual Group. All Rights Reserved. Page 1 of 1 Ed. 061011!2011 NOTICE OF CANCELLATION TO THIRD PARTIES A. If we cancel this policy for any reason other than nonpayment of premium, we wfl, notify the persons or organizations shown in the Schedule below. We will send notice to the email or mailing address listed below at least 10 days, or the number of days listed below, if any, before cancellation becomes effective. In no event does the notice to the third party exceed the notice to the first named insured. B. This advance no'dfication of a pending cancellation of coverage is intended as a courtesy only. Our failure to provide such advance notification will not extend the policy cancellation date nor negate cancellation of the policy. Schedule Name of Other Person(s)! Email Address or mailing address: Number Days Notice: Organization(s): Per schedule on file with the 90 company All other terms and conditions of this policy remain unchanged. Issued by Liberty Insurance Corporation 21814 For allachrrrent to Policy No. WC7-641.005097-033 Effective Date Fremium $ Issued to Certenniai Energy HoUngs, Inc. WM 90 18 06 11 © 2011, Liberty Mutual Group. All Rights Reserved. Page 1 of 1 Ed. 0610112011