HomeMy WebLinkAboutInsurance Certificate: Pacific Paving Inc
PAC108C OP ID: HSA
DATE (MM/DD/YYYY)
ACOR06 CERTIFICATE OF LIABILITY INSURANCE
03/11/2015
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 NCONTACT
AME: Therese Rayburn
United Risk Solutions, Inc. PHONE FAX
PO Box 936 A/c No E,):641-245-1111 A/C, No l: 541-245-1112
Medford, OR 97501-0067 ADDRESS:
Jim R. Cox SS: therese.rayburn@unitedrisk.com
INSURER(S) AFFORDING COVERAGE NAIC #
INSURER A: Western National Assurance Co 24465
INSURED Pacific Paving, Inc INSURER B :
PO Box 2370
White City, OR 97503 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.
IN SR ADDL SUBR POLICY EFF POLICY EXP LIMITS
LTR TYPE OF INSURANCE POLICY NUMBER MM/DDIYYYY MM/DD/YYYY
A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,00
CLAIMS-MADE X OCCUR X CPP107021802 03/2012015 03/2012016 DAMA E T R N 300,00
PREMISES Ea occurrence $
MED EXP (Any one person) $ 10,00
PERSONAL & ADV INJURY $ 1,000,00
GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,00
X POLICY ❑ PRO L-1 LOC PRODUCTS - COMP/OP AGG $ 2,000,00
JECT
OTHER: $
AUTOMOBILE LIABILITY COEaMBINED accidentSINGLE LIMIT $ 1,000,00
A X ANY AUTO CPP106912802 03/20/2015 03/20/2016 BODILY INJURY (Per person) $
ALL OWNED SCHEDULED BODILY INJURY (Per accident) $
AUTOS AUTOS
NON-OWNED PROPERTY DAMAGE $
HIRED AUTOS AUTOS Per accident
UMBRELLA LIAB OCCUR EACH OCCURRENCE $
EXCESS LIAB CLAIMS-MADE AGGREGATE $
DED RETENTION $ $
WORKERS COMPENSATION PER OTH-
AND EMPLOYERS' LIABILITY Y/N STATUTE ER
ANY PROPRIETOR/PARTNER/EXECUTIVE E.L. EACH ACCIDENT $
OFFICER/MEMBER EXCLUDED? ❑ N/A
(Mandatory in NH) E.L. DISEASE - EA EMPLOYEE $
If yes, describe under
DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT $
DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required)
City of Ashland is hereby named as additional insured per form
WNGL39 (03/10)
CERTIFICATE HOLDER CANCELLATION
CITAS01
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.
Kari Olson Purchasing Rep
90 N. Mountain Ave. AUTHORIZED REPRESENTATIVE
Ashland, OR 97520-2014 O~ • ~
1988-20144 A~COORRD CORPORATION. All rights reserved.
ACORD 26 (2014/01) The ACORD name and logo are registered marks of ACORD
l
WN GL 39 03 10
COMMERCIAL GENERAL LIABILITY ENHANCEMENT ENDORSEMENT
The Commercial General Liability Enhancement Endorsement is an optional endorsement that provides coverage
enhancements. The following is a summary of broadened coverages provided by this endorsement. No coverage is
provided by this summary, refer to following endorsement for changes in your policy.
SUMMARY OF COVERAGES PAGE
Bodily Injury And Property Damage Liability
• Non Owned Watercraft Up To 50 Feet 2
Property Damage Liability
Elevators ............................................................................................................................3
• Fire, Lightning, Explosion Or Sprinkler Leakage Exception ..................................................3
• Borrowed Equipment ($25,000 Per Occurrence, $50,000 Aggregate,
$2,500 Deductible Per Occurrence 3
Supplementary Payments -Amended
Bail Bonds Up To $5,000 3
• Loss of Earnings Up To $500/Day .......................................................................................3
Who Is An Insured Amendments
• Employee Bodily Injury To A Co-Employee 4
Newly Formed Or Acquired Organizations For Up To 180 Days 4
Blanket Additional Insured - Vendors - As Required By Contract 4
• Blanket Additional Insured - Lessor Of Leased Equipment .................................................5
Blanket Additional Insured - Managers Or Lessors Of Premises 5
Blanket Additional Insured - State Or Governmental Agency Or Subdivision
Or Political Subdivision - Permits Or Authorizations 5
Blanket Additional Insured - State Or Governmental Agency Or Subdivision
Or Political Subdivision - Permits Or Authorizations Relating To Premises .......................5
N
Damage To Premises Rented To You - $300,000
N
N
O
O
Medical Payments Increased Limit - $10,000 Or Amount Shown on Declarations 6
Conditions o
Knowledge of Accident, Claim, Suit Or Loss Amended ........................................................6
• Unintentional Failure To Disclose Hazards 6
• Waiver of Subrogation .........................................................................................................6 0
Bodily Injury Redefined To Include Mental Anguish ..........................................................................6
Insured Contract Amended ..............................................................................................................6
Personal And Advertising Injury Redefined
• Televised, Videotaped Or Electronic Publication ..................................................................6
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THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY
COMMERCIAL GENERAL LIABILITY ENHANCEMENT ENDORSEMENT
This endorsement modifies the insurance provided under the following:
COMMERCIAL GENERAL LIABILITY COVERAGE FORM
With respect to the coverage provided by this endorsement, the provisions of the Coverage Form apply unless modified
by this endorsement. The SECTIONS of the Commercial General Liability Coverage Form identified in this endorsement
will be amended as shown below.
SECTION I - COVERAGES AMENDMENTS (5) "Bodily injury" or "property damage" arising
out of
COVERAGE A - BODILY INJURY AND PROPERTY
DAMAGE LIABILITY (a) The operation of machinery or
equipment that is attached to, or part of,
A. Non Owned Aircraft Or Watercraft a land vehicle that would qualify under
Item 2. Exclusions, Paragraph g. is replaced by the the definition of "mobile equipment" if it
were not subject to a compulsory or
following: financial responsibility law or other
g. Aircraft, Auto Or Watercraft motor vehicle insurance law in the state
where it is licensed or principally
,Bodily injury" or "property damage" arising out garaged; or
of the ownership, maintenance, use or
entrustment to others of any aircraft, "auto" or (b) The operation of any of the machinery
watercraft owned or operated by or rented or or equipment listed in Paragraph L (2)
loaned to any insured. Use includes operation or f. (3) of the definition of "mobile
and "loading or unloading". equipment".
This exclusion applies even if the claims against B. Damage To Property Coverage Extensions
any insured allege negligence or other
wrongdoing in the supervision, hiring, Item 2. Exclusions, Paragraph J. is replaced by the
employment, training or monitoring of others by following:
that insured, if the "occurrence" which caused j. Damage To Property
the "bodily injury" or "property damage" involved
in the ownership, maintenance, use or "Property damage" to:
entrustment to others of any aircraft, "auto" or
(1) Property you own, rent, or occupy, including
watercraft that is owned or operated by or any costs or expenses incurred by you, or
rented or loaned to any insured. any other person, organization or entity, for
This exclusion does not apply to: repair, replacement, enhancement,
restoration or maintenance of such property
(1) A watercraft while ashore on premises you for any reason, including prevention of injury
own or rent; to a person or damage to another's
(2) A watercraft you do not own that is: property;
(a) Less than 50 feet long; and (2) Premises you sell, give away or abandon, if
the "property damage" arises out of any part
(b) Not being used to carry persons or of those premises;
property for a charge; (3) Property loaned to you;
This Subparagraph (2) applies to any
person, who with your expressed or implied (4) Personal property in the care, custody or
consent, either uses or is responsible for the control of the insured;
use of the watercraft; (5) That particular part of real property on which
you or an contractors or subcontractors ei$ "x
(3) Parking an "auto" on, or on the ways next to, y y l
premises you own or rent, provided the working directly or indirectly on your behalf "auto" is not owned by or rented or loaned to are performing operations, if
the "property
you or the insured; damage" arises out of those operations; or
(4) Liability assumed under any "insured (6) That particular part of any property that
contract" for the ownership, maintenance or must be restored, repaired or replaced
use of aircraft or watercraft; or because "your work" was incorrectly
performed on it.
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WNGL390310
Paragraphs (1), (3) and (4) of this exclusion do not C. Damage To Premises Rented To You
apply to "property damage" (other than damage by
fire, lightning, explosion or sprinkler leakage) to Item 2. Exclusions, the last paragraph is replaced
premises, including the contents of such premises, by the following:
rented to you for a period of 7 or fewer consecutive Exclusions c. through n. do not apply to damage by
days. A separate limit of insurance applies to fire, lightning, explosion or sprinkler leakage to
Damage To Premises Rented To You as described premises while rented to you or temporarily
in SECTION 111 - LIMITS OF INSURANCE. occupied by you with permission of the owner. A
However, the provisions of this paragraph do not separate limit of insurance applies to this coverage
apply if coverage for Damage To Premises Rented as described in Paragraph 6. of SECTION III -
To You is excluded by endorsement. LIMITS OF INSURANCE.
Paragraph (2) of this exclusion does not apply if the
premises are "your work" and were never occupied, COVERAGE B - PERSONAL AND ADVERTISING
rented or held for rental by you. INJURY LIABILITY
Paragraphs (3) and (4) of this exclusion do not apply D. Personal And Advertising Injury
to the use of elevators. Item 2. Exclusions is amended by replacing
Paragraphs (3), (4), (5) and (6) of this exclusion do Sub-paragraphs b. and c. with the following:
not apply to liability assumed under a sidetrack b. Material Published With Knowledge Of
agreement.
Falsity
Paragraph (4) of this exclusion does not apply to
"property damage" to borrowed equipment while not "Personal and advertising injury" arising out of
at the jobsite. oral, written, televised, videotaped or electronic
being used to perform operations
publication
Subject to Paragraph 2. of SECTION III -LIMITS of material, if done by or at the
OF INSURANCE, the rules below fix the most we direction of the insured with knowledge of its
falsity
will pay for "property damage" under this provision: '
(1) $25,000 any one "occurrence", regardless of the c. Material Published Prior To Policy Period
number of persons or organizations who sustain "Personal and advertising injury" arising out of
damages because of that "occurrence": oral, written, televised, videotaped or electronic
(2) $50,000 annual aggregate: and publication of material whose first publication
took place before the beginning of the policy
(3) We will pay only for damages in excess of period.
$2,500 as a result of any one "occurrence",
regardless of the number of persons or SUPPLEMENTARY PAYMENTS - COVERAGES A
N organizations who sustain damages because of AND B
that "occurrence". We may, or if required by
N law, pay all or any part of any deductible E. Supplementary Payments - Coverages A and B
S amount, if applicable, to effect settlement of any Item 1. is amended by replacing Subparagraphs b.
claim or "suit". Upon notice of our payment of a and d. with the following:
deductible amount, you shall promptly reimburse
us for the part of the deductible amount we paid. b. Up to $5,000 for cost of bail bonds required
because of accidents or traffic law violations
Paragraph (6) of this exclusion does not apply to arising out of the use of any vehicle to which the
"property damage" included in the Bodily Injury Liability Coverage applies. We do
"products-completed operations hazard". not have to furnish these bonds.
The insurance provided for "property damage" from d. All reasonable expenses incurred by the insured
the use of elevators and for "property damage" to at our request to assist us in the investigation or
borrowed equipment is excess over any other valid defense of the claim or "suit", including actual
and collectible property insurance (including any loss of earnings up to $500 a day because of
deductible portion thereof) available to the insured time off from work.
whether primary, excess, contingent or on any other
basis.
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WNGL390310
SECTION II - WHO IS AN INSURED AMENDMENTS d. Repackaging, except when unpacked solely
for the purpose of inspection,
A. Employee Bodily Injury To A Co-Employee demonstration, testing, or the substitution of
Paragraph 2. a. (1) is replaced by the following: parts under instructions from the
manufacturer, and then repackaged in the
(1) "Bodily injury' or personal and advertising original container;
injury": e. Any failure to make such inspections,
(a) To you, to your partners or members (if you adjustments, tests or servicing as the
are a partnership or joint venture), to your vendor has agreed to make or normally
members (if you are a limited liability undertakes to make in the usual course of
company), or to your other "volunteer business, in connection with the distribution
workers" while performing duties related to or sale of the products;
the conduct of your business;
f. Demonstration, installation, servicing or
(b) For which there is any obligation to share repair operations, except such operations
damages with or repay someone else who performed at the vendor's premises in
must pay damages because of the injury connection with the sale of the product;
described in Paragraph (1) (a) above; or
(c) Arising out of his or her failing 9• Products which, after distribution or sale by
9 providing or g you, have been labeled or relabeled or used
to provide professional health care services. as a container, part or ingredient of any
B. Newly Acquired Organizations other thing or substance by or for the
vendor; or
Paragraph 3. a. is replaced by the following: h. "Bodily injury or "property damage" arising
a. Coverage under this provision is afforded only out of the sole negligence of the vendor for
until the 180th day after you acquire or form the its own acts or omissions or those of its
organization or the end of the policy period, employees or anyone else acting on its
whichever is earlier; behalf. However, this exclusion does not
apply to:
The following are added: (1) The exceptions contained in
C. Blanket Additional Insured - Vendors - As Subparagraphs d. or f.; or
Required By Contract (2) Such inspections, adjustments, tests or
Section II - Who Is An Insured is amended to servicing as the vendor has agreed to
include as an additional insured any person(s) or make or normally undertakes to make in
organization(s) (referred to below as vendor) with the usual course of business, in
whom you have agreed in a written contract, connection with the distribution or sale
executed prior to loss, to name as an additional of the products.
insured, but only with respect to "bodily injury" or 2. This Provision C. does not a
"property damage" arising out of "your products" pph'
which are distributed or sold in the regular course of a. To any insured person or organization from
the vendor's business, subject to the following whom you have acquired such products, or
additional exclusions: any ingredient, part or container, entering
1. The insurance afforded the vendor does not into, accompanying or containing such
apply to: products;
a. "Bodily injury" or "property damage" for b. To any vendor for which coverage as an
which the vendor is obligated to pay additional insured specifically is scheduled
damages by reason of the assumption of by endorsement; or
liability in a contract or agreement. This c. When liability included within the
exclusion does not apply to liability for "products-completed operations hazard" has
damages that the vendor would have in the been excluded for such product either by the
absence of the contract or agreement; provisions of the coverage part or by
b. Any express warranty unauthorized by you; endorsement
i'•n•:
c. Any physical or chemical change in the
product made intentionally by the vendor;
WN GL 39 03 10 Includes copyrighted material of Insurance Services Office, with its permission Page 4 of 6
WN GL 39 03 10
D. Blanket Additional Insured - Lessor Of Leased 2. This insurance does not apply to:
Equipment a. "Bodily injury", "property damage" or
1. Section 11 - Who Is An Insured is amended to "personal and advertising injury" arising out
include as an additional insured any person or of operations performed for the federal
organization from whom you lease equipment government, state or municipality; or
when you and such person or organization have b. "Bodily injury" or "property damage"
agreed in writing in a contract or agreement, included within the "products-completed
executed prior to loss, that such person or operations hazard".
organization be added as an additional insured
on your policy. Such person or organization is G. Blanket Additional Insured - State Or
an insured only with respect to liability for "bodily Governmental Agency Or Subdivision Or
injury", "property damage" or "personal and Political Subdivision - Permits Or Authorizations
advertising injury" caused, in whole or in part, by Relating To Premises
your maintenance, operation or use of Section 11 - Who Is An Insured is amended to
equipment leased to you by such person or include as an insured any state or governmental
organization. agency or subdivision or political subdivision with
A person's or organization's status as an whom you have agreed in a written contract,
additional insured under this endorsement ends executed prior to loss, to name as an additional
when their contract or agreement with you for insured, subject to the following provision:
such leased equipment ends. This insurance applies only with respect to the
2. With respect to the insurance afforded to these following hazards for which the state or
additional insureds, this insurance does not governmental agency or subdivision or political
subdivision has issued a permit or authorization in
apply to any "occurrence which takes place connection with premises you own, rent or control
after the equipment lease expires. and to which this insurance applies:
E. Blanket Additional Insured - Managers Or 1. The existence, maintenance, repair,
Lessors Of Premises construction, erection or removal of advertising
section 11 - Who Is An Insured is amended to signs, awnings, canopies, cellar entrances, coal
include as an insured any person or organization holes, driveways, manholes, marquees, hoist
away openings, sidewalk vaults, street banners
with whom you have agreed in a written contract,
executed prior to loss, to name as an additional or decorations and similar exposures; or
insured, but only with respect to liability arising out of 2. The construction, erection or removal of
the ownership, maintenance or use of that part of elevators; or
the premises leased to you, subject to the following 3. The ownership, maintenance or use of any
additional exclusions: elevators covered by this insurance.
N This insurance does not apply to:
N
1. Any "occurrence" which takes place after you SECTION III - LIMITS OF INSURANCE
cease to be a tenant in that premises. AMENDMENTS
2. Structural alterations, new construction or
demolition operations performed by or on behalf A. Damage To Premises Rented To You
of such additional insured. Paragraph 6. is replaced by the following: s
s
F. Blanket Additional Insured - State Or 6. Subject to Paragraph S. above, the most we will
Governmental Agency Or Subdivision Or pay under Coverage A for damages because of
Political Subdivision - Permits Or Authorizations "property damage" to any one premises, while
Section 11 - Who Is An Insured is amended to rented to you, or in the case of damage by fire,
include as an insured any state or governmental lightning, explosion or sprinkler leakage, while
agency or subdivision or political subdivision with rented to you or temporarily occupied by you
whom you have agreed in a written contract, with permission of the owner is the greater of
executed prior to loss, to name as an additional a. $300,000; or
insured, subject to the following provisions:
b. The amount shown next to the Damage To
1. This insurance applies only with respect to Premises Rented To You Limit in the
operations performed by you or on your behalf Declarations.
for which the state or governmental agency or However, the provisions of this paragraph do not
subdivision or political subdivision has issued a apply if Damage To Premises Rented To You
permit or authorization.
Coverage is excluded by endorsement.
WN GL 39 03 10 Includes copyrighted material of insurance Services Office, with its permission Page 5 of 6
WN GL 39 03 10
B. Medical Expense Limit your policy, we will not derry coverage under
this Coverage Part because of such failure.
Paragraph 7. is replaced with the following: However, this provision does not affect our
7. Subject to Paragraph S. above, the most we will right to collect additional premium or
pay under Coverage C for all medical expenses exercise our right of cancellation or
because of "bodily injury" sustained by any one non-renewal.
person is the greater of D. Waiver of Subrogation
a. $10,000; or SECTION IV - COMMERCIAL GENERAL
b. The amount shown next to the Medical LIABILITY CONDITIONS, 8. Transfer of Rights of
Expense Limit in the Declarations. Recovery Against Others to Us is hereby
This insurance does not apply if coverage for amended by the addition of the following:
Medical Expenses is excluded either by the We waive any right of recovery we may have
provisions of the coverage part or by because of payments we make for injury or damage
endorsement. arising out of your ongoing operations or "your work"
SECTION IV -COMMERCIAL GENERAL LIABILITY done under a written contract, executed prior to loss,
requiring such waiver with that person or
CONDITIONS AMENDMENTS organization and included in the
A. Knowledge Of occurrence "products-completed operations hazard". However,
our rights may only be waived prior to the
Item 2. Duties In The Event Of Occurrence, "occurrence" giving rise to the injury or damage for
Offense, Claim or Suit is amended by adding the which we make payment under this Coverage Part.
following: The insured must do nothing after a loss to impair
e. You must give us or our authorized our rights. At our request, the insured will bring
representative prompt notice of an "occurrence", "suit" or transfer those rights to us and help us
claim or loss only when the "occurrence", claim enforce those rights.
or loss is known to:
(1) You, if you are an individual; SECTION V - DEFINITIONS AMENDMENTS
(2) A partner, if you are a partnership: A. Bodily Injury Redefined
(3) An executive officer or insurance manager, Paragraph 3. "Bodily injury" is replaced by the
if you are a corporation; or following:
(4) A member or manager, if you are a limited 3. "Bodily injury" means bodily injury, sickness or
liability company. disease sustained by a person, including death
B. Other Insurance resulting from any of these at any time. "Bodily
injury" includes mental anguish or other mental
Item 4. Other Insurance, b. Excess Insurance (1) injury resulting from such bodily injury.
(a) (ii) is replaced by the following:
B. Insured Contract Amended
(ii) That is fire, lightning, explosion or sprinkler
leakage insurance for premises rented to you or Paragraph 9. a. is replaced by the following:
temporarily occupied by you with permission of a. A contract for a lease of premises. However,
the owner, that portion of the contract for a lease of
C. Unintentional Failure To Disclose Hazards premises that indemnifies any person or
organization for damage by fire, lightning,
Paragraph 6. Representations is replaced by the explosion or sprinkler leakage to premises while
following: rented to you or temporarily occupied by you
6. Representations And Unintentional Failure with permission of the owner is not an "insured
To Disclose Hazards contract";
a. By accepting this policy, you agree: C. Personal And Advertising Injury Redefined
(1) The statements in the Declarations are Paragraph 14. d. and e. are replaced by the
accurate and complete; following:
(2) Those statements are based upon d. Oral, written, televised, videotaped or electronic
representations you made to us; and publication of material that slanders or libels a
person or organization or disparages a person's
(3) We have issued this policy in reliance or organization's goods, products or service;
upon your representations.
e. Oral, written, televised, videotaped or electronic
b. If you unintentionally fail to disclose any publication of material that violates a person's
hazards existing at the inception date of right of privacy;
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