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HomeMy WebLinkAboutInsurance Certificate: C-2 Utility Contractors "ik- 010® CERTIFICATE OF LIABILITY INSURANCE page 1 of 1 0417/2013 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 NAM Willie of Pennsylvania, Inc. PHONE FAX c/o 26 Century Blvd. N XT 877-945-7378 a N 888-467-2378 F. O. Box 305191 AE-MARIL certificates@willis.com Nashville, TN 37230-5191 INSURER(S)AFFORDING COVERAGE NAIC. INSURER A: Liberty mutual Fire Insurance Company 23035-001 INSURED C-2 Utility contractors, LLC INSURER B: Liberty Insurance Corporation 42404-001 33005 Roberts Court INSURERC: Coburg, OR 97408 INSURER D: INSURER E: I INSURER F COVERAGES CERTIFICATE NUMBER: 19745826 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 DO' SUB POLICY NUMBER POLICY EFF POLICY EXP LIMITS A GENERALUABIUTY Y TB2631004260012 7/31/2012 7/31/2013 EACHOCCURRENCE $ 5,000,000 X COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED PREMISES Ea occurence $ 11000,000 CLAIMS-MADE~OCCUR MED EXP(my one person) $ PERSONAL B ADV INJURY $ 51000,000 GENERALAGGREGATE $ 5 000 000 GENT AGGREGATE LIMIT APPLIES PER. PRODUCTS'COMP/OPAGG $ 5,000,000 POLICY X PRO- F-1 LOC JECT A AUTOMOBILELIABILITY AS2631004260022 7/31/2012 7/31/2013 COMBINED SINGLE LIMIT (Ea awdent s 5,000,000 X ANY AUTO - BODILY INJURY(Per person) 5 ALLOWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS X MIRED AUTOS X NON-OWNED PROPERTYDAMAGE AUTOS Per accident $ 8 UMBRELLA LAS OCCUR EACHOCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE 5 DED RETENTIONS S STAI B WORKERS COMPENSATION WA763DO04260032 7/31/2012 7/31/2013 X W H AND EMPLOYERS' LIABILITY T RY R B ANY PROPRIETOWPARTNER/EXECUTIVEY N/A WC7631004260042 7/31/2012 7/31/2013 E.L. EACH ACCIDENT $ 110001000 OFFICEWMEMBER EXCLUDED? _ (Mandatpryln NH) - E.L. DISEASE - EA EMPLOYEE $ 1,000,000 umde, 1111 yes, describe H) DESCRIPTION OFOPERATIONS below EL DISEASE. POLICY LIMIT S 1,000,000 DESCRIPTION OF OPERATIONS/ LOCATIONS /VEHICLES (Ahach Acord 101, Addhonel Remark. schedule, if more space is required) Workers' Compensation in State of Washington is Self Insured. The City of Ashland and its elected officals, officers & employees are included as Additional Insureds as respects to General Liability as required by written contract. CERTIFICATE HOLDER CANCELLATION 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 City of Ashland 20 East Main Street ' Ashland, OR 97520 Coll:4069677 Tp1:1486747 Cert:19745826 ©1988-2010ACORD CORPORATION. All rights reserved. ACORD 25 (2010/05) The ACORD name and logo are registered marks of ACORD Policy Number: TB2631004260012 & AS2631004260022 Endorsement Number: LA 99 224 09 10 Issued by: Liberty Mutual Fire Insurance Company & Liberty Mutual Fire Insurance Company Endorsement Effective Date: 7/31/2012 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 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 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 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- a 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): City of Ashland 20 East Main StreetfiAshland, OR 97520 30 All other terms and conditions of this policy remain unchanged. LA 99 224 09 10 Page 1 of 1 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. In no event does the notice to the third party exceed the notice to the first named insured. B. This advance email 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): City of Ashland 20 East Main StreetCAshland, OR 30 97520 WA7-63D-004260-032 (AOS) WC7-631-004260-042 (OR & WI) Effective: 7/31/2012 Expiration: 7/31/2013 All other terms and conditions of this policy remain unchanged. WM 90 18 09 10 2010 Liberty Mutual Group of Companies Page I of 1 Ed. 09/01/2010 All Rights Reserved