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HomeMy WebLinkAboutInsurance Certificate: Pilot Rock Excavation 9PILORO OP ID: JS CERTIFICATE OF LIABILITY INSURANCE 0 DAT7/17D/YYYY) 07/17/13 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- certiflcate holder in lieu of such endorsements . - - - - - - - PRODUCER 541-779-4232 CONTACT Hart Insurance - NAME: 1123 Royal Ave. 541-772-3963 H INC. ' ON No EMI: - AAIC. X No): - - - Medford, OR 97504 E-MAIL Hart Insurance / Medford' ' - ADOaess: INSURERS AFFORDING COVERAGE NAICa INSURER A: Cincinnati Insurance 10677 - INSURED Pilot Rock Excavation Inc INSURERS: 650 E Pine St Ste 102b Central Point, OR 97502 INSURER C: INSURER D : INSURER E : INSURER F : COVERAGES CERTIFICATE NUMBER: 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 rypE OF INSURANCE POLIO EFF POLICY UP LTR POLICY NUMBER MM/DD/YYYY (MMIDDrrrM LIMITS III= JNM GENERAL LIABILITY EACH OCCURRENCE E 1,000,00 A X COMMERCIAL GENERAL LIABILITY X EPP0151857 07/20113 07/20/14 PREMISES Me accunence $ 1,000,00 CLAIMS-MADE OCCUR MED UP (Any are person) $ 16,00 PERSONAL B ADV INJURY $ 1,000,00 GENERAL AGGREGATE 'E 2,000,00 GENT AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG E- - 2,000,00 X POLICY P'0. LOC - - - $ - - - AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT 1,00000 Ea accident B ANY AUTO EBA0151857 07/20/13 07/20114 BODILY INJURY (Per person) $ - ALL OWNED X SCHEDULED AUTOS AUTOS BODILY INJURY (Par accident) $ - X MIRED AUTOS X NON-OWNED PROPERTY DAMAGE § AUTOS Par accident $ X UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 1,000,00 A E%CE33 LU1B CLAIMS-MADE EPP0151867 - 07120/13 07120114 AGGREGATE $ 1,000,00 DED X RETENTION $ 10,000 § WORKERS COMPENSATION WC STATU- OTM- AND EMPLOYERS' LIABILITY YIN ITS IR ANY PROPRIETOR/PARTNERIEXECUTIVE E.L. EACH ACCIDENr $ OFFICER/MEMBER EXCLUDED? F7N/A (Mandatory In NH) E.L. DISEASE-EA EMPLOYEE $ n y s, deaaibe under DESCRIPTION OF OPERATIONS below F.. L. DISEASE -POLICY LIMIT $ A Lease/Rented Equip EPPOIS1857 07/20/13 07/20114 Limit 100,00 Ded. 50 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ANach ACORD 101, Additional Remarks Schedule, If mom space Is required) City of Ashland and its employees, officers and agents are included as additional insured as respects to general liability per form GA233 02/07 attached. CERTIFICATE HOLDER CANCELLATION CITYASH SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN City of Ashland ACCORDANCE WITH THE POLICY PROVISIONS. 20 E. Main Street Ashland, OR 97520 AUTH ZED 4P ESENT edf Hart s ce / edford © 9 8-201 CORP ION. All rights reserved. ACORD 25 (2010/05) The ACORD name and logo a regis red arks of ACORD cess of the deductible amount (1) Any person or organization de- stated In Section B. Limits of scribed In Paragraph 9.a(2) be- Insurance, 6. Voluntary Prop- low (hereinafter referred to as e ty Damage and Care, Cus- additional insured) whom you tody or Control Liability Cov- are required to add as an addi- erage or this endorsement. The tional Insured under this Cover- limits of insurance will not be re- age Part by reason of: duced by the application of such deductible amount. (a) A written contract or agree- ment; or (2) Condition 2. Duties In the (b) An oral agreement or oon- Event of Occurrence, Offense, tray where agreement or of Claim or Suit, applies to each claim or 'suit" Irrespective of the insurance showing that par- amount. son or organization as an additional insured has been (3) We may pay any part or all of issued, the deductible amount to effect is an insured, provided: settlement of any claim or "suit" pres and, upon notification of the ac- (a) The written or oral contract tion taken, you shall promptly re- or agreement is: imburse us for such part of the deductible amount as has been 1) Currently In effect or paid by us. becomes effective dur- the policy period; 7. 180 Day Coverage for Newly Formed or in and Acquired Organizations SECTION II - WHO IS AN INSURED is 2) Executed prior to an "occurrence" or offense amended as follows: to which this Insurance Subparagraph a. of Paragraph 4. is would apply; and hereby deleted and replaced by the fol- (b) They are not specifically lowing: named as an additional in- a. Insurance under this provision is af- sured under ary other pro- forded only until the 180th day after vision of, or endorsement you acquire or form the organization added to, this Coverage or the end of the policy period, Part. whichever is earlier; (2) Only the following persons or 8. Waiver of Subrogation organizations are additional in- sureds under this endorsement, SECTION IV -COMMERCIAL GENERAL and Insurance coverage pro- LIABILITY CONDITIONS, 9. Transfer of vided to such additional insureds Rights of Recovery Against Others to is limited as provided herein: Us is hereby amended by the addition of the following: (a) The manager or lessor of a premises leased to you with We waive any right of recovery we may whom you have agreed per have because of payments we make for Paragraph 9.a.(1) above to injury or damage arising out of your ongo- provide insurance, but only ing operations or "your work" done under with respect to liability aris- a written contract requiring such waiver Ing out of the ownership, with that person or organization and in- maintenance or use of that cluded In the "products-completed opera- part of a premises leased to lions hazard". However, our rights may you, subject to the following only be waived prior to the "occurrence" additional exclusions: giving rise to the Injury or damage for which we make payment under this Cov- This insurance does not ap- erage Part. The insured must do nothing ply to: after a loss to Impair our rights. At our 1) Any "occurrence" which request, the Insured will bring "suit" or takes place after you transfer those rights to us and help us en- cease to be a tenant In force those rights. that premises. 9. Automatic Additional Insured - Sped- 2) Structural alterations, fled Relationships new construction or a. The following is hereby added to demolition operations SECTION II -WHO IS AN INSURED: performed by or on be- Includes copyrighted material of Insurance GA 233 02 07 Services Office, Inc., with Its permission. Page 10 of 15 half of such additional solely for the pur- insured. pose of inspection, (b) Any person or organization demonstration, from which you lease testing, or the equipment with whom you substitution of have agreed per Paragraph parts under In- 9.a(1) above to provide in- structions from the s rance. Such manufacturer, and person(s) or then repackaged solely with rearespect to their Insureds in the original con- liability arising out of the tamer; maintenance, operation or e) Any failure to use by you of equipment make such inspec- leased to you by such per- bore, adjustments, son(s) or organization(s). tests or servicing However, this Insurance as the vendor has does not apply to any "oc- agreed to make or currence" which takes place normally under- after the equipment lease takes to make in expires. the usual course (C) Any person or organization of business, In connection with (referred to blow as ven- the distribution or dor) with Mom you have sale of the prod- agreed per er Paragraph 9.a(l) above to provide in- ucts; surarwe, but only with re- f) Demonstration, in- spect to "bodily Injury" or stallation, servic- 'property damage" arising ing or repair op- out of `your products" which erations, except are distributed or sold in the such operations regular course of the van- performed at the does business, subject to vendor's premises the folkrMng additional ex- In connection with clusions: the sale of the 1) The insurance afforded product; the vendor does not g) Products which, apply to: after distribution or a) 'bodily injury" or sale by you, have "property damage" been labeled or re- labeled or used as for which the veto a container, part or dor is obligated to ingredient of any pay damages other thing or sub- reason of the ass- - stance by or for sumption of Ilabil- the vendor. Ity in a contract or agreement. This 2) This Insurance does exclusion does not rat apply to arry in- apply to liability for sured person or organi- damages that the zaton: vendor would have in the absence of a) From whom you the contract or have acquired agreement; such products, or any Ingredient, b) Any express war- part or container, ranty unauthorized entering into, ac- by you; companying or C) Any physical or containing such chemical change products; or In the product b) When liability in- made intentionally cluded within the by the vendor; "products- completed opera- llore hazard" has unless unpacked Includes copyrighted material of Insurance GA 233 02 07 Services Office, Inc., with Its permission. Page 11 of 15 been excluded Any person or organization under this Cover- with which you have agreed age Part with re- per Paragraph 9.a.(1) above sped to such to provide Insurance, but products. only with respect to liability (d) Any state or political subdi- arising out of "your work" vision with which you have performed for that additional agreed per Paragraph insured by you or on your behalf. A person or organi- suran above to provide in- zation's status as an Insured fol- lowing dW to the under this provision of this lowing additional l provision: : endorsement continues for This Insurance applies only only the period of time re- with rasped to the following qulred by the written con- hazards for which the state tract or agreement, but In no or political subdivision has event beyond the expiration issued a permit In connec- date of this Coverage Part. tion with premises you own, If there is no written contract rent or control and to which or agreement, or If no pe- this Insurance applies: Hod of time is required by the written contract or 1) The existence, mainte- agreement, a person or or- nance, repair, construc- ganizati n's status as an in- tion, erection, or re- sured under this endorse- naval of advertising ment ends when your op- signs, awnings, cano- erations for that Insured are pies, cellar entrances, completed. coal holes, driveways, ' manholes, marquees, (3) Any Insurance provided to an hoist away openings, additional Insured designated sidewalk vaults, street under Paragraph 9.a.(2): banners, or decorations (a) • Subparagraphs (e) and and similar exposures; does not apply to 'bodily in- or jury" or "property damage" 2) The oonstructon, erec- included within the "prod- tion, or removal of ale- ucts-completed operations vators; or hazard"; 3) The ownership, main- (b) Subparagraphs (a), (b), (d), tenanoe, or use of any (e) and (f) does not apply to elevators covered by bodily injury", 'property this insurance. damage" or "personal and advertising Injury" arising (e) Any state or political subdi- out of the sale negligence or vision with which you have willful misconduct of the ad- agreed per Paragraph ditional insured or their 9.a.(1) above to provide In- agents, "employees" or any surance, subject to the fol- other represerdative of the lowing provisions: additional Insured; or 1) This insurance applies (c) Subparagraph (f) does not only with respect to op- apply to bodily ir1'ury", erations performed by "property damage" or "per- you or on your behalf sonal and advertising Injury' for which the state or arising out of political subdivision has Issued a permit. 1) Defects in design fur- nished by or on behalf 2) This insurance does of the additional in- not apply to "bodily In- sured; or jury", "property dam- age' or 'personal and 2) The to rendering rener, of, any advertising injury' arcs- failure y Ing out of operations professional architec- perfonned for the state tural, engineering or or political subdivision. surveying services, In- cluding: Includes copyrighted material of Insurance GA 233 02 07 Services Office, Inc., with its permission. Page 12 of 15 a) The preparing, primary to other insurance approving or fall- available to the additional ing to prepare or insured except: approve maps, shop drawings, 1) As otherwise provided opinions, reports, in SECTION IV - surveys, field or- COMMERCIAL GEN- ders, change or- ERAL LABILITY CONDITIONS, S. ders or drawings and speclIcations; Other Insurance, b. and Excessinsurance;or b) Supervisory, In- 2) For any other valid and spection, archhec- collectible insurance tural or engineer- available to the addi- Ing activities. tional insured as an additional insured by 3) "Your work" for which a attachment of an en- consolidated (wrap-up) dorsement to another insurance program has insurance policy that is been provided by the written on an excess pdmecontractor-project basis. In such case, manager or owner of the coverage provided the construction project under this endorsement in which you are In- shall also be excess. valved. (2) Condition 11. Conformance to b. Only with regard to Insurance pro- Specific Written Contract or vided to an additional Insured desig- Agreement is hereby added: nated under Paragraph 9.a.(2) Sub- paragraph (f) above, SECTION III - Specific LIMITS OF INSURANCE Is amended Written Contract or to include: Agreement The limits applicable to the additional With respect to additional insured are those specified in the insureds described in Para- written contract or agreement or in graph 9.a(2)(f) above only: the Declarations of this Coverage If a written contract or Part, whichever are less. If no limits are specified In the written contractor agreement between you agreement, or if there Is no written and the additional Insured contract or agreement, the limits ap- specifies that coverage for pliable to the additional Insured are the additional insured: those spedfied In the Declarations of a. Be provided by the In- this Coverage Part. The limits of in- surance Services Office surance are inclusive of and not in additional insured form addition to the limits of Insurance number CG 20 10 or shown in the Declarations. CG 20 37 (where edi- e. SECTION N - COMMERCIAL GEN- tion specified); or ERAL LIABILITY CONDITIONS is b. Include coverage for hereby amended as follows: completed operations; (1) Condition 5. Other Insurance is or amended to include: c. Include coverage for (a) Where required by a written your work"; contract or agreement, this and where the limits or eov- insurance is primary and / erage provided to the addi- or nonwntdbutory as re- tional Insured Is more re- spects any other insurance strictive than was specfi- policy Issued to the addi- cally required in that written tional insured, and such contract or agreement, the other Insurance policy shall terms of Paragraphs be excess and / or noncan- 9.a(3)(a), 9.a(3)(b) or 9.b. tdbuting, whichever applies, above, or any combination with this insurance. thereof, shall be interpreted (b) Any Insurance provided by as providing the limits or this endorsement shall be coverage required by the terms of the written contract Includes copyrighted material of Insurance GA 233 02 07 Services Office, Inc., with Its permission. Page 13 of 15 or agreement, but only to (c) Persons or organizations the extent that such limits or making claims or bring coverage Is Included within "Suits". the terms of the Coverage Part to which this endorse- (2) Deductible Clause ment is attached. If, how- (a) Our obligation to pay dam- ever, the written contract or ages on your behalf applies agreement specifies the In- only to the amount of dam- " surance Services Office ad- ages for each "occ rrrenoa" ditional Insured form num- which are in excess of the ber CG 20 10 but does not Deductible amount stated In specify which edition, or Section B. Limits of Insur- specifies an edition that ante, 11. of this endorse- does not exist, Paragraphs ment. The limits of Insur- 9.a.(3)(a) and 9.a.(3)(b) of ante will not be reduced by this endorsement shall not the application of such De- apply and Paragraph 9.b. of ductible amount. this endorsement shall ap- ply. (b) Condition 2. Duties in the 10. Broadened Contractual Liability - Work Event of Occurrence, Of- Within 50' of Railroad Property plies to each claim or °suiC' It Is hereby agreed that Paragraph f( l) of irrespective of the amount. Definition 12 'Insured oontract' (SEC- (c) We may pay arry part or all TION V -DEFINITIONS) Is deleted. of the deductible amount to 11. Property Damage to Borrowed Equip- effect settlement of any ment claim or "suit' and, upon no- tification of the action taken, a. The following is hereby added to Ex- you shall promptly reim- clusion)Damage to Property of burse us for such part of the Paragraph 2., Exclusions of SEC- deductible amount as has TION 1 -COVERAGES, COVERAGE been paid by us. A. BODILY INJURY AND PROP- ERTY DAMAGE LIABILITY: 12. Employees as Insureds - Specified Health Care Services Paragraphs (3) and (4) of this exdu- sion do not apply to tools or equip- It Is hereby agreed that Paragraph ment loaned to you, provided they 2.a I(d) of SECTION 11 - WHO IS AN are not being used to perform opera- INS RED, does not apply to your "em- tions at the time of loss. ployees" who provide professional health care services on your behalf as duly li- b. With respect to the Insurance pro- censed: vided by this section of the endorse- ment, the following additional provi- a. Nurses; sions apply: b. Emergency Medical Technicians; or (1) The Limits of insurance shown in c. Paramedics, the Declarations are replaced by the limits designated In Section In the jurisdiction where an "occurrence" B. Limits of Insurance. 11. of or offense to which this insurance applies this endorsement with respect to takes place. coverage provided by this en- dorsement. These limits are in- 13. Broadened Notice of Occurrence clusive of and not in addition to Paragraph a. of Condition 2. Duties in the limits being replaced. The the Event of Occurrence, Offense, Limits of Insurance shown in Claim or Suit (SECTION IV -COMMER- Section B. Limits of Insurance, CIAL GENERAL LIABILITY CONDI- 11. of this endorsement fix the TIONS) is hereby deleted and replaced most we will pay in anyone "oc- by the following: curence" regardless of the number of., a. You must see to It that we are notl- a Insureds; tied as soon as practicable of an "oc- currence* or an offense which may (b) Claims made or "suits" result In a claim. To the extent pos- brought; or sible, notice should Include: (1) How, when and where the "oc- currence" or offense took place; Includes copyrighted material of Insurance GA 233 02 07 Services Office, Inc., with Its permission. Page 14 of 15