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HomeMy WebLinkAboutInsurance Certificate: Knife River Materials 2011 DATE YVYV CERTIFICATE OF LIABILITY INSURANCE 17/2011(MIAD 2011 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 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 endorsements . PRODUCER CONTACT Marsh USA Inc. NAME: 333 South 7th Street, Suite 1600 PHONE Ar No : Minneapolis, MN 554022400 E-MAIL ADDRESS, Attn: cmtrad.reviewCSS@marshcan INSURER(S) AFFORDING COVERAGE NAIC# 143750-LTM-GAWX-12-13 2010 2037 2048 At Y INSURER A: Liberty Mutual Fire Ins Co 23035 INSURED INCORPORATED LTM, INSURER B: Associated Electric & Gas Ins Services Ltd 3190004 DBA KNIFE RIVER RIVER MATERIALS INSURER C : Liberty Mutual Insurance Company 23043 PO BOX 1145 INSURER D: MEDFORD, OR 97501 INSURER E INSURER F : COVERAGES CERTIFICATE NUMBER: CHI-004334737-07 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. INSR TYPE OF INSURANCE ADDL SUBR POLICY EFF POLICY UP LTA POLICY NUMBER MWDD YYY MMIDD/VYYY LIMITS A GENERAL LIABILITY TB2641005097-042 0110112012 0110112013 EACHOCCURRENCE $ 2,000,000 X COMMERCIAL GENERAL LIABILITY DAMA RENTED 500,000 PREMISE E occurrence $ CLAIMS-MADE M OCCUR MED UP An me person) $ 10,000 X PER PROJECT AGGREGATE PERSONAL S ADV INJURY $ 2,000,000 GENERALAGGREGATE $ 4,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP/OP AGG $ 4,000,000 POLICY PRO LOG $ A AUTOMOBILE LIABILITY AS2 641 005097-052 0110112012 0110112013 COMBINED SINGLE LIMIT 2000000 Ea accitl n _ X ANY AUTO BODILY INJURY (Per person) $ ALL OWNED SCHEDULED AUTOS AUTOS BODILY INJURY (Per accident) $ NON-0WNED PROPERTY DAMAGE $ X HIRED AUTOS X AUTOS Peramitl n B UMBRELLA LIAR HOCCUR XL5063401P 0110112012 0110112013 EACH OCCURRENCE $ 5,000,000 X E%CFSS LIAR CLAIMS-MADE AGGREGATE $ 5,000,000 )ED RETENTION $ G WORKERS COMPENSATION WC7-641-005097-022(Guar. Cost) 0110112012 0110112013 X WC STATUS OTH- AND EMPLOYERS' LIABILITY CRY "M T I G ANY PROPRIETORIPARTNERIEXECUTIVE YIN WA7-64D-005097 012 (ADS) 0110112012 0110112013 E.L. EACH ACCIDENT $ 1,000,000 C OFFICENMEMBER EXCLUDED? ~ NIA WC7-641-005097-032 OR,WI 01/0112012 0110112013 (Mandatwy in NH) ( ) E.L. DISEASE - EA EMPLOYE $ 1,000,000 If as, describe under 'Includes'Sto Ga 1,000,000 DESCRIPTION OF OPERATIONS bebw p P E.L. DISEASEPOLICY LIMIT $ DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (Attach ACORD 101, Additional Remarks Schedule, it more space is required) Re: All Operations City of Ashland is/are included as additional insured per the allached CG 2010 and CG 2037 endorsements and does not include professional liability coverage. Blanket Additional Insured for Automobile Liability is ncluded per attached designated Insured Endorsement CA 20 48. Excess lability applies to general liability, products and completed operations, automobile liability, and employers liability. CERTIFICATE HOLDER CANCELLATION City of Ashland SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Attn: Kan Olsen THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 90 N. Mountain ACCORDANCE WITH THE POLICY PROVISIONS. Ashland, OR 97520 AUTHORUMD REPRESENTATIVE of Marsh USA Inc. Manashi Mukherjee j+toL~,aooa: 4°'~ ®1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25 (2010/05) The ACORD name and logo are registered marks of ACORD Policy Number AS2$41-005097-052 Issued by LIBERTY MUTUAL FIRE INSURANCE COMPANY 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 Schedule Name of Other Person(s) ! Email Address or mailing address: Number Days Notice: Organization s : Per Schedule on file with the 90 company 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 99 01 05 11 © 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 modified 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 provisions of the Coverage Form apply unless modified by this endorsement This endorsement identifies person(s) or organization(s) who are "insureds" under the Who Is An Insured Provision of the Coverage Form. This endorsement does not after coverage provided in the Coverage Form. SCHEDULE Name of Person(s) or Any person or organization whom you have agreed in writing to add as an additional Organization(s)' Insured, but only to coverage and minimum limits of insurance required by the written agreement and in no event to exceed either the scope of coverage or the limits of insurance provided in this policy. 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" under the Who Is An Insured Provision contained in Section 11 of the Coverage Form. Policy No: AS2-641-005097-052 Issued By: Lberty Mutual Fire Insurance Company Effective Date: 1/1/2012 Expiration Date: 1/1/2013 CA 20 48 02 99 Copyright, Insurance Services Office, Inc., 1998 Page 1 of 1 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - OWNERS, LESSEES OR CONTRACTORS - COMPLETED OPERATIONS This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Name Of Additional Insured Person(s) Location And Description Of Completed Operations Or Organization(s): Any person or organization for whom you have agreed in writing prior to a loss to provide liability insurance Information required to complete this Schedule if not shown above will be shown in the Declarations. 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 "properly 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". This endorsement Is executed by the LIBERTY MUTUAL FIRE INSURANCE COMPANY Premium $ EffectNe Date 111/2012 Expiration Date 1/.1/2013 For attachment to Policy No. T62-641-005097-042 Audit Basis Issued To CG 20 37 07 04 0 ISO Properties, Inc., 2004 Page f of f 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 Additional Insured Person(s) Location(s) Of Covered Operations Or Organization(s): Any owner, lessee or contractor from whom you have agreed in writing prior to a loss to provide liability insurance Information required to complete this Schedule if not shown above, will be shown in the Declarations. A. Section II - Who Is An Insured is amended to B. With respect to the insurance afforded to these include as an additional insured the person(s) or additional insureds, the following additional exciu- organization(s) shown in the Schedule, but only sions apply: with respect to liability for "bodily injury, "property This insurance does not a damage' or "personal and advertising injury apply to "bodily injury" or "property damage" occurring after: caused, in whole or in part, by: 1. Your acts or omissions; or 1. All work, including materials, parts or work, ment furnished in connection with such wo work, 2. The acts or omissions of those acting on your on the project (other than service, maintenance behalf; or repairs) to be performed by or on behalf of in the performance of your ongoing operations for the additional insured(s) at the location of the the additional insured(s) at the location(s) desig- covered operations has been completed; or nated above. CG 20 10 07 04 C ISO Properties, Inc., 2004 Page 1 of 2 2. That portion of your work' out of which the injury or damage arises has been put to its in- tended use by any person or organization other than another contractor or subcontractor en- gaged in performing operations for a principal as a part of the same project. This endorsement is executed by the LIBERTY MUTUAL FIRE INSURANCE COMPANY Premium $ Effective Date 1/112012 Expiration Date 1/112013 For attachment to Policy No. T82-641-005097-042 Audit Basis Issued To Page 2 of 2 © ISO Properties, Inc., 2004 CIS 20 10 07 04 Policy Number TB2-641-005097-042 Issued by LIBERTY MUTUAL FIRE INSURANCE COMPANY THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ R 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 Schedule Name of Other Person(s)! Email Address or mailing address: Number Days Notice: Organization(s): Per Schedule on file with the 90 company 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. UM 99 01 05 11 © 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 CHANGESTHE POLICY. PLEASE READ IT CAREFULLY. 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 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. SCHEDULE Name of Other Person(s) J Email Address or mailing address: Number Days Notice: Organization(s): Per Schedule on file with the 90 company Al other terms and conditions of this policy remain unchanged. Issued by LIBERTY INSURANCE CORPORATION For attachment to Policy No. WC7-641-005097-032 Effective Date 01/01/2012 Premium $ Issued to WM 90 18 06 11 © 2011 Liberty Mutual Group of Companies Page 1 of 1 Ed. 06/01/2011 All Rights Reserved THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. 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 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. SCHEDULE Name of Other Person(s) I 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 For attachment to Policy No. WA7-64D-005097-012 Effective Date 01101/2012 Premium $ Issued to AM 90 18 06 11 © 2011 Liberty Mutual Group of Companies Page 1 of 1 Ed. 06/01/2011 All Rights Reserved 0000651 SP 03B4 -C02-P00651-1 City of Ashland Attn: Kari Olsen 90 N. Mountain Ashland, OR 97520 THIS ENDORSEMENT CHANGESTHE POLICY. PLEASE READ IT CAREFULLY. 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 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. 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 For attachment to Policy No. WC7.641-005097-022 Effective Date 01/01/2012 Premium $ Issued to WM 90 18 06 11 © 2011 Liberty Mutual Group of Companies Page 1 of 1 Fol. 06101/2011 All Rights Reserved