HomeMy WebLinkAboutInsurance Certificate: Knife River Materials
® DATE (MM/DD/YYYY)
ACOR" CERTIFICATE OF LIABILITY INSURANCE 12/14/2015
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 CONTACT
Marsh USA Inc. NAME:
PHONE 333 South 7th Street, Suite 1400 IA/C No xt : A/C No):
Minneapolis, MN 55402-2400 E-MAIL
Attn: MDU.CertRequest@marsh.com ADDRESS:
INSURERS AFFORDING COVERAGE NAIC #
J43750-LTMM-GAWX-16-17 2010 2037 LTMMe Al Y INSURER A : Liberty Mutual Fire Ins Co 23035
INSURED LTM, 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 D :
MEDFORD, OR 97501
INSURER E
INSURER F :
COVERAGES CERTIFICATE NUMBER: CHI-005204108-17 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 INADDL SD SUWVD ER POLICY NUMBER MM/DD YYYY MML
LTR DD YYYY LIMITS
A X COMMERCIAL GENERAL LIABILITY TB2-641-005097-046 01/0112016 01/01/2017 EACH OCCURRENCE $ 2,000,000
DAMAGE TO RENTED
CLAIMS-MADE X OCCUR PREMISES Ea occurrence $ 500,000
X PER PROJECT AGGREGATE MED EXP (Any one person) $ 10,000
PERSONAL & ADV INJURY $ 2,000,000
GEN'L AGGREGATE LIMIT APPLIES PER. GENERAL AGGREGATE $ 4,000,000
POLICY ❑ PRO JECT 1:1 LOC PRODUCTS - COMP/OP AGG $ 4,000,000
OTHER. $
A AUTOMOBILE LIABILITY AI2-641-005097-056 01/01/2016 01/01/2017 COMBINED SINGLE LIMIT $ 2,000,000
Ea accident
X ANY AUTO BODILY INJURY (Per person) $
ALL OWNED SCHEDULED BODILY INJURY (Per accident) $
AUTOS AUTOS
X X NON OWNED PROPERTY DAMAGE $
HIRED AUTOS AUTOS Per accident
B UMBRELLA LIAB OCCUR XL5063405P 01/01/2016 01/01/2017 EACH OCCURRENCE $ 5,000,000
X EXCESS LIAB CLAIMS-MADE AGGREGATE $ 5,000,000
DED RETENTION$ $
C WORKERS COMPENSATION WC2-641-005097-026 (Guar. Cost) 01/01/2016 01/01/2017 X PER orH-
AND EMPLOYERS' LIABILITY STATUTE ER
C ANY PROPRIETOR/PARTNER/EXECUTIVE Y/N WA7-64D-005097-016 (ADS) 01/01/2016 01/01/2017 E L EACH ACCIDENT 1,000,000
~
OFFICER/MEMBER EXCLUDED? N/A "Includes "Stop-Gap 1,000,000
(Mandatory in NH) $ EL DISEASE - EA EMPLOYEE $
If yes, describe under 1,000,000
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)
Re: All Operations
City 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 Liability is included per attached designated Insured Endorsement CA 20 48. Excess liability 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
AUTHORIZED REPRESENTATIVE
of Marsh USA Inc.
ManashiMukherjee ~M#(~gM/yj L~cfc.►ez
@ 1988-2014 ACORD CORPORATION. All rights reserved.
ACORD 25 (2014101) The ACORD name and logo are registered marks of ACORD
tAicy Nurriber., A12-6411-00-5097-056
Issueaby: L,IBEIR° Y ~11I'lI'. L.FIR I'ISI_.IIi_~~l<_': (°t.}~~f'"~'
°I HI s ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
NOTICE OF CANCELLATION TO THIRD PARTIES
This endorsement modifies insurance prat ded ~indear the following:
BUSINESS AUTO COVERAGE PART
MOTOR CARRIER COVERAGE PART
GARAGE COVERAGE PART
TRUCKERS COVERAGE 'ART
EXCESS AUTOMOBILE LIA 1LLITY INDEMNITY COVERAGE: LAR17
SELF-INSURED 'I RUCKER EXCESS LIABILITY COVERAGE FART
COMMERCIAL GENLR.AL I.IABIL.17"Y° (',OVERAGE PAR
EXCESS COMMERCIAL GENERAL LIABILITY S OVtLRAGE PART
PRODUCT&COMPLETED C;PFRAT°`ONS LIABILIT`! COVERAGE PART
LIQUOR LIABILITY COVERAGE PART
C(aML4ERCIAL LIABILITY - UMBRELLA COVERAGE FORM
Schedule
a me of Other I er trrr(s Email Address or mailing addres : Number Days mice.
f3ra ~Izatlc~rr s
Per schedule ref cerl€f c at Fe sc'h .d ile of cert0hcate Icicle. ~ can 90
holders. on file with h ~ file with the Company.
i
M.. -
A If we cancel this policy for any reason other than norip ayarrant o p<re:miurn, we spill notify the persons or
organizations shown in the shed.r c above, We will:. end notice to the er'nail or rnailir°,g address listed above
at lust 10 r ays, or t e~ number of days listed above, if any, before the cancellation becoarea effective. In no
event drams the notice tc' the third party exceed the sic i e to the first turned insured
B, This advance. notification of a perdircg cancellation rjf coo rage is intended as a uourtesy°onlyt_ Our fai urc to
provide such advance notification wH riot extend the ~xil cy cancellation date nor negate r:rncellation of the-
policy.
All other terns and conditions of this policy remain unchariged,
4-
LINT 99 01 5 11 c-k, 2011 i ibwl I«luldal Croup of Companies. All right's reserved= Wage 1 of 1
Includes copyrighted material of Insurance Services Offs.. Inc_ wittt
its permission.
POLICY PlUfv9E ER: Al's-tit 005097-056 COMMERCIAL AUTO
CA 20 48 10 13
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE DEAD IT CAREFULLY,
DESIGNATED COVERED AUTOS LIABILITY COVERAGE
This enc!orsem~ent riaoc .fies insurwice provided under the following:
AUTO DEALERS COV; - :RAGE FORM
BUSINESS AUTO COVILRAGIL FORt.1
K10 TOR CARRIER COVERAGE FORM
V itht respect to coverage provided by this endorsement, the provision6 of ttie C=overage 1-orn-i apply unfess
rt udified by this endor~--ement.
This endor4 ern •tt identifies person(s) or organization(S) Who sire °iiISUreds" for Covered Autos LiaO.Jity Coverage
under The VVo Is An li-ast,ired provision o° the u-a°a:rie Fori-i.. This e€-i=:iorsc:i-i-ie;rit f1c:es ii,3, alter cover~'Ic..r
provided in the Coverage
For,-SCHEDULE
Name Of Person(s) Or Organization(s):
Any person or organization whom you have agreed, in vvritin to add as an additional insured, but only, to
cove-rage and rriir€ m am limits of it s.arance rec aired by the writlen agreement, and in no event to exweed either
the scope of coverage or the limits of insurance provided in th€s pony.
i
This policy will be primary and non-contributory' to ary, lime insurarice ava1ab e to tide person cr € rgai€ s aU00
noted above..
_w
lnfco-rr-n, _o n rip ed, f a complete uriis S ;hiedule, if not shown above, wol be shown n the Uecl . oti°,}
Each persor or organization shown in the. Schedule is
art "insured" for C civered Autos Liability Coverage, but
Clniy to the r xte `rt that person or rare anizatiol, qua if=es:
as an X.sured" under the Who Is An Insured
provisicari € ont.ai er. in Paragraph A.1, of Section if -
Covered AWto Liability C£)srera-fle in the,. Business-
Auto anc. Motor C .rrier Coverage I-orms and
Par=igtaph 11.2, of Sec,<ir,ra l Covered Autos
Coverages of the Auto Dealers Co:+erape Form.
A 0 4 10 13 es lnsur;a€€ we Swv ces Office; Inc,: 2011 Page 1 of 1
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
ADDITIONAL INSURED ORGANIZATION
CONTRACTORS - SCHEDULED PERSON OR
This endorsement modifies ir~sr.irar~co r?roridecl cinder the following,
COMMERCIAL, GIENIFRAL LIABILITY COVERAGE PART
SCHEDULE
Fame Of Additional Insured Person(sj ~ Location( s) Of Covered Operations
Or ter anizatiart ;
Any persons', or organizations for whofn yrm have Al ocations as required in wriwtg and agreed to
agreed in L°Jnfi1 ig, prior to an "occurrence" or prior to car, "raccurrpi" ce ` ter offense,
rAferrse to provide add tional insured s<atus.
-
informat on re Mired to c22 e e this chedu,le, if not shown riho=v n in the Declarations,
A. Section II - Who Is An Insured is amended to B. With respect to the ins.,rance affwdec1 to ia;s ;
include as an additional insured the. person(s) Or additional insureds, the following additional exciu-
urr;iini eatiori(s) shown in the Schedule, but only sods apply,
with respect to =iability for "bodily in ury", "property This Insurance does not appiy to bcdi y injury" or
damage" or "personal anc adverfisi:lg injury" "property darria~:o" cx Xc r~irtc, aftof:
rausa& in whole or irepart, try
1. All work, including materials, parts or ecfulp-
1. yo x a .ts r r r~, iis:?oa€a; or rr ent furnished, n connection mthi s~Fch work,
. The acts or ornimons of those acting on your on the project (other than service, maintenance
behalf; or repairs) to n performed by or or tier}at` of
in the performarce of your ongoing operations for the a+ di ioriM it s ired(s) at the location of thc,
the additional insured(s) at the il,3Ce]tlt3 }j { dE?si - covered operations has, been cor7° Noted or
nated above.
20 10 07 04 16:, 60 Prope. -ties, Inc,., 2004 Paget of 2
iZ ` .at aertfon of "your work" out of which the
injury or damage arises has beers peat to its in
tendrad use by any person, or org.-inizaticii other
than anothf-r n1ra+: for gar subcontractor en-
gaged in Ser€eYriin operations for a principal
as a part of the tsame project.
f ilia w€ r3cx cr'err~ 14, >exee itcsd by tha: I_ F.RT`r' N1JTUAi- Ff" IN-,' URAtXE COMPANY
f c'::tESw)rlE ~s
FP` r Ci B I -t L xp r ttiv, Ll w
F< ,r attachr? ent to iftk;y NoE f X2_6,:; f 00!,19 -046
~.k :;if Iaa~ss
)~~suod To
vLJ C`tr:r:a€Ls'€9t,„Lf by
Is Aj vd Sales utfi;; e, acrd N";. Er3,;, se; ki No.
Page 2 of 2 €a ISO Propeerties, Inc., 2004 2010 7 04
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE BEAD IT CAREFULLY.
ADDITIONAL INSURED CONTRACTORS - OPERATIONS
COMPLETED T ks wndorsement modifies it-G ..ranee pra"vide+ under the follovling
COMMERCtAL GENERAL LIABILITY COVERAGE PART
HAUL
~
Name Of Additional insured Person(s) Location And Description Of Completed Operations
Or Or nization s
Any pe=se-nE~s or organizations for whom you have A I iocatioris as required ins writing, and agreed to
A-aqreed in writing, prior to an feoccurre8 ce" or pnoi to an `:M ccurreFgr.p" or offens e.
"offense", to provide dditiorai insured status.
€
Infrinnat€on equiredd to con plete this cheduie f not shown above, €1€ be show n in tl ~ De a. 0ns.
Section 11 - Who 1e An Insured is amended to
in€;Iude as an addTonal insured the person(s) or
organizations shown in Ilhe Schedule, but only with
respect to liability for "bodily injury" or "property darn-
age" caused, in whole or in part, by "Your ~.vork" at
the location de signatec and described in the sched-
u`e of this endorsement performed for that addit un a
insured and r clod d in the "1 root,cts-completed
rate-;nation hazard".
Tha. €and rs ament Is exece.€teo by the Uit EE IY € UT A RIRF INSURANCE COMPANY
Prerr:fum
E-te-.4,ve Ugte Exp€ ntion Coal:
For attachrrs..~nt tin Eatiry No T82-641-+,'0509-04
t;ud:f Bat,=5
IssLed To
r rir5 SaIQ, i OffEC c and 6. r-. d. X. i.1 `In.
CCU 20 7 07 04 T,,,; ISO Properties, Inc.. 2004 Page 1 of I
THIS ENDORSEMENT CHANGES THE POLICY. 'LEASE READ IT CAREFULLY.
NOTICE OF CANCELLATION TO THIRD PARTIES
This end > se :ent i?.odifies incur qcw provid -d under the fcllowin :
BUSINESS AUTO CjCWE= RACE PART
MOTOR CARRIER COVERAGE PART
GARAGE COVERAGE-' PART
TRUCKERS COVERAGE FART
EXCESS AUTO€vfGSILE LIABILITY aN EMNIT" CO'VERAG& PART
SELF INSURED TRUCKER EXCESS I..IABII..ITY COVERAGE PART
4:OM,VE1= CIAL GENERA=L. LIABILITY COVERAGE RAFT
EXCESS COMMERCIAL GENERAL LIABILITY C (',Vf RA(-,,E PART
PRODUC TS,`C Ot,1PLEI ED Cr.>PERA DNS LIABILITY COVERAGE PART
LIQUOR I IA ILI I Yr' COVERAGE PART
C€-4AMIERCIAL LIA IL<T Y I.JMORELLA COVERAGE FORM
Schedule
Nears of O her I'ursunEz Ti Email Address or mailing address. Day eatEce:
Or r s tic~ri s
Per Schedule of cr rtifi ate,
holders d
E
i
A: If kye cancel this p-licy for am rc i lr- r 1,•,er than narip ayniant of firurmuin, .,ve e9.°€'IE roc zJy Ilia Defsor s or
or ad i .-Bans `+I-town in the SchL-d '~..ii` 6. }`'~E`~: wilI s-cn i notice to The email or .cis€ng w"1 ~L~rE m: I t= 6~ %7I!'~i'
at 'east 10 €!ciys od the ;nf..@l:ibe of C :-y I zr bove, if iny, -t-Iore the can-.0aflon becornes e:flt'+.;Vve In no
event does the rotice to the Iii€rd party e~c.I::ad the notice tc, ttie fist ?a;,fried i lsuff-d.
E; This advance notification of a ending cancellation of roverawe is ± i ¢ratled as a rof.l tasyr oply, Our fa I..3re, flD
provide si;ic,ii advarce notifvrat3on aMll not extend Vw- pf.di:.: t ~ r~ : a f:3td )r? CIr~tE: i,w riE.WAe c;an::e 1:rtbi i of thc,
policy-
All other te~rrrs and conditions of this poij- y rani°;adri uris;I€~n~~ al
LIM 99 0105 11 C-) 2011 Liberty Mutual Cfou d of Con-,pan es. All rights resc8rvec. R, I of 'l
Includes opy-y of Insurance ervfceCffa , In vith
htecrra#erla t; r}fir%12d53id"3ri.
NOTICE OF N LLaATION TO THIRD PARTIES
A„ If wa cancel this jiolic,y for ar y reasun, ether man nompayment of ptrerniIurri, we Wi€[ notr v the persons or
organizali 5n s 'Shown in ti' e ,S t,f?dt.4c belo`v, ~Ne will sf;'.C'd notice to the ernaii or maii€rtg c3ddresa listed Lwow at
least 1,0 days:, or the rf€. tuber of days l shed below, €f any. hetore car€cellation becoj?es efjec,tive. In no even',
does the notice to the third paH exceed the, no ice. to the firs, named rn ;.,,re ,
This advance notification of a fending cancf- Matron of cove.ra c is intended as a cf7€<r esy (rjtr+, Our fail€!fc to
pr gvide such advance notification w M not extcn3d the paolic.,, cancellation dale nor gale ca ,cet€ xtton of t4€
policy.
Schedule
Name of Other Person(s) t Entail address or mailing address: Number Days Notice:
Organization (s):
Pei c'hedule of certitica'e ~?f)
hNders on `i=.e e' ti the
company
All other iprm s and ccnd tions of this 3:31 %,t femain tmchangr-d,
issued by Ll urty msuran, C' L r~ 'AP"siCrtb`I 21314
F 2r aftac.!-t€rm"t t.~ PCiji;v K~o T,,TA"-644-()0 300) 1 6 b t ffe€ fv( [)a Q 0111 t1 ' Ct 1 CJ l'; ,i2 s.tra i
a
1,~53.ae: ;c i.a_~,nni<sl En>v.fty
i° w,.&=x
WFA 90 18 06 11 0 2011, L it Frily Mut='..ai Gf'ou.p.. All f ioht Reservpid pagtr t of 1
Ed, 06t010i11
NOTICE OF CANCELLATION TO THIRD PARTIES
A If We can ;a:t this fpollcy for any °eascn ctne than. nnr f ay<rrpr1rit Of prern um, we vJ11 raulify the perEcons or
€ fganizations shown in the &,hed say p bf-Ic)vv VVe will send, nctit e to fh, ~ m> vii ar rr aii,og acldre:ss [isteQ b0l)vv at
least 1C days, or the nui inner of d,-,,ys listed ,ac low, € any, t.ofare cance lation beconnes effedjive, in no vvent
does the CSC,',: s:, tF: ,'h thired f; any tote notine to the first P?edt'. ec instpred,
B. T his adS,farTc" f"9ctifi r'B, S<on of a jmt nC` inq.. <°;aP'lceilation of 1::LisdC.w=ge is € -?lg-`.'-1i,wl as a GCIirte- sy Ou,, fa:, Ue to
prf-Mt. e such advance ncfificaLion aril no extend the. patirsx cancellation date nof' negate cancellation of the
Schedule
Nate of Other Person(s) I Email Address or mailing address, Number [days Notice:
Organization (s):
per s&iod le of :,Kbficalp, 9
Ali' other term- and cony:.'€ti pns Ear this poky reiy'tn; n [.I?:i;ha nge ,
1~,sued by €._Ed of-:,,, MAoat F;i' €d, r is€cs C € npgpany 6586
For atla ,r'ii' is P =l In Pnlicy No r,' > COLS 1 -00`109 74).26 u, cuv Date 6 1 J",) 1 t 34? i 6 p+!e#l. wi
WM 90 18 0 11 w, 2011, ibervv kl. I1 ial t src3up At€ ghtc; Reserve page, of 1
Ed. 0&'0112011