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HomeMy WebLinkAboutInsurance Certificate: Knife River Materials A~ CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDDYYYY) 12112I2013 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 endorsement(s). PRODUCER CONTACT Marsh USA Inc. NAME: [A/C, No Erb- HONE AIC No 333 South 7N Street, Suite 1400 P Minneapolis, MN 55402-2400 E-MAIL Attn: mntrack.revieWCSS@mamh.Lom ADDRESS: INSURERS AFFORDING COVERAGE RAIC p J43750-LT%C,AWX-14.15 2010 2037 LTMMe At Y INSURER A : Liberty Muual Fire Ins Co 23035 INSURED LTA, INCORPORATED INSURER B: Associated Electric & Gas Ins Services Ltd 3190004 DBA KNIFE RIVER MATERIALS INSURER C: Liberty Mutual Insurance Company 23043 PO BOX 1145 INSURER p MEDFORD, OR 97501 INSURE E R NSURER F : COVERAGES CERTIFICATE NUMBER: CHI-004334737-11 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, EXCLUSIONSAND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCE ADDL UBR POLICY EFF POLICY EXP LTR POLICY NUMBER MM/DDMW MMIDD/YYYY LIMITS im Jim A GENERAL LIABILITY TB2-641-005097-044 0110112014 01/01/2015 EACH OCCURRENCE $ 2,000,000 X COMMERCIAL GENERAL LIABILITY AMA E T ELATED 500,000 PREMISES Eaa .R. $ CLAIMS-MADE O OCCUR MED EXP (Any one person) $ 10,000 X PER PROJECT AGGREGATE PERSONAL&ADV INJURY $ 2,000,000 GENERALAGGREGATE It 4,000,000 GENT AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP/OP AGG $ 4,000,000 1-1 POLICY PRO LOC $ JECT A AUTOMOBILELIABILITY AI2-641-005097-054 0110112014 OV01/2015 COMBINED SINGLE LIMIT Eaacci 2,000,000 dent X ANY AUTO BODILY INJURY (Per person) $ ALL OWNED SCHEDULED BODILY INJURY (Per accident) $ AUTOS AUTOS NON-OWNED PROPERTY DAMAGE $ X HIRED AUTOS X AUTOS Per accident $ B UMBRELLA LIAB OCCUR XL5063403P 01/0112014 01/01/2015 EACH OCCURRENCE $ 5,000,000 X EXCESS LIAB CLAIMS-MADE AGGREGATE $ 5,000,000 DIED RETENTIONS $ C WORKERS COMPENSATION WC7.641-005097-024(Guar. Cost) 0110112014 01101/2015 X WC STAru- OTH- ANp EMPLOYERS' LIABILITY LIMITS ER C ANY PROPRIETOR/PARTNERIEXECUTIVE r/e WA7-64D005097-014 (ADS) 0110112014 0110112015 1,000,000 E.L OFFICERIMEMBER EXCLUDED? NIA E.L. EACH ACCIDENT $ (Mandatory in NH)IDCudes'$lOp-Gap° E.L. DISEASE-EA EMPLOYE $ 1,000,000 U es, describe under 1,000,000 DESCRIPTION OF OPERATIONS below E.L. DISEASE. POLICY LIMIT $ DESCRIPTION OF OPERATIONS I LOCATIONS /VEHICLES (Attach ACORD 101, Additional Remarks Schedule, H more space is required) Re: All Operations Gty of Ashland is/are included as additional insured per the attached CG 2010 and CG 2037 endorsements and does not include professional liability Coverage. Blanket Additional Insured for Automobile Uadlity is included per attached designated Insured Endorsement CA 2048. Excess liability applies to general liability, products and completed operations, automobile liability, and Employers liability. CERTIFICATE HOLDER CANCELLATION CityofAshland SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Attn: Kad 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. Manashi Mukhegee -~N(nuaal4 e-c ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25 (2010105) The ACORD name and logo are registered marks of ACORD Policy Number AI2-641-005097-054 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: Organizations : Per schedule of certificate 90 holders on file with the 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. Policy Number TB2-641-005097-044 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 of certificate 90 holders on file with the coma n 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. 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 of certificate holders on file with the company 90 All other terms and conditions of this policy remain unchanged. Issued by Liberty Insurance Corporation For attachment to Policy No. WAY-64D-005097-014 Effective Date 01/01/2014 Premium $ Issued to WM 90 1 a 06 11 © 2011 Liberty Mutual Group of Companies Page 1 of 1 Ed. 06101/2011 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)! Email Address or mailing address: Number Days Notice: Organization(s): Per schedule of certificate holders on file with the company 90 All other terms and conditions of this policy remain unchanged: Issued by Liberty Insurance Corporation For attachment to Policy No. WC7-6411005097-024 Effective bate 01/01/2014 Premium $ Issued to WM 90 18 06 11 © 2011 Liberty Mutual Group of Companies Page 1 of 1 Ed. 06101/2611. All Rights Reserved POLICY NUMBER: AI2-641-005097-054 COMMERCIAL AUTO CA 20481013 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. DESIGNATED INSURED FOR COVERED AUTOS LIABILITY COVERAGE This endorsement. modifies insurance provided under the following: AUTO DEALERS COVERAGE FORM BUSINESS AUTO COVERAGE FORM MOTOR CARRIER 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" for Covered Autos Liability Coverage under the Who Is An Insured provision 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 whom you have agreed in writing to add as an additional 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 This policy will be primary and non-contributory to any like insurance available'to the person or organization . noted above. Information required to complete this Schedule, if not shown above, will be shown in the Declarafions. Each person or organization shown in the Schedule is an "insured" for Covered Autos Liability Coverage, but only to the extent that person or organization qualifies as an "insured" under the Who Is An' Insured provision contained in Paragraph A.1. of Section II - Covered :Autos Liability Coverage in the Business Auto and Motor Carrier Coverage Forms and Paragraph D.2. of Section I - Covered Autos Coverages of the Auto Dealers Coverage Form. CA 20 48 1 0 13. © Insurance Services Office, Inc., 2011 Page 1 of 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: All persons or organizations with whom you have entered into a written contract or agreement, prior to an "occurrence" or "offense", to provide additional insured status and.specifically requiring this version of the endorsement. (If no entry appears above, information required to complete this endorsement will be shown in the Declarations as applicable to this endorsement.) A. Section II - 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 add]- 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 © 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 FIRE INSURANCE COMPANY Premium $ Effective Date Expiration Date For attachment to Policy No, TB2-641-005097-044 Audit Basis' Issued To Countersigned by _ Authorized Representative Issued. Sales Office and No. End. Serial No. Page 2 of 2 @ ISO Properties, Inc., 2000 CG 20 10 10 01 POLICY NUMBER: T62-641.005097-044 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 modifies insurance provided under the following: COMMERCIAL GENERAL LIABirryCOVERAGE 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 "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". SCHEDULE Name Of Additional Insured Person(s) Or Organization(s): Location And Description Of Completed Operations All persons or organizations.with whom you have All locations as required by a written contract or entered into a written contract or agreement, prior to an agreement entered into prior to an "occurrence" or 'occurrence" or offense, to provide additional insured offense. status. Information required to complete this Schedule, if not shown above, will be shown in the Declarations. CG: 20 37 07 04 G ISO Properties, Inc., 2004 Page 1 of 1