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HomeMy WebLinkAboutInsurance Certificate: Pacific Paving Inc PAC108C OP ID: ANH E(MM/DDIYYYY) ACORO CERTIFICATE OF LIABILITY INSURANCE 7OT3/16/2016 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 Holly Avritt NAME~ Propel Insurance PHONE 541 -245-1111 a 541-245-1112 formerly United Risk Solutions JA/c. No,Exty No) PO Box 936 EE-M Be Medford, OR 97501-0067 ss: holly.avritt@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 t INSURER D : INSURER E : INSURER F : COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT TFIF POLICIES OF INSURANCE I ISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREME;.i, TERM 2R CONDITION OF ANY' CONTRACT OR OTHER DCCUMEAT 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 ADD iL SUBR POLICY EFF POLICY EXP LIMITS LTR TYPE OF INSURANCE POLICY NUMBER MM/DD/YYYY MM/DDIYYYY A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,00 DAME T RENTED CLAIMS-MADE X OCCUR X CPP107021803 03/20/2016 03/20/2017 _PREMISES ~Ea occurrence $ 300,000 MED EXP (Any one person) $ 10,000 PERSONAL & ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: _ PRODUCTSGCOMP/OP AGG $ 2,000,000 t PRO- X, , - $ 2,000,00 POLICY JECT LOC OTHER: AUTOMOBILE LIABILITY Eaa acct dentl_LE LIMIT $ 1,000,000 A X ANY AUTO 11CPP106912803 03/20/2016 03/20/2017 BODILY INJURY (Per person) $ ALL OWNED F SCHEDULED BODILY INJURY (Per accident): $ AUTOS - NAUTOS ON-OWNED PROPERTY DAMAGE $ (Per accident)- HIRED AUTOS - AUTOS $ OCCUR EACH OCCURRENCE $ 1,000,000 UMBRELLA LIAB X - - A X EXCESS LIAB - CLAIMS-MADE iUMB101591302 10/15/2016 03/20/2017 F AGGREGATE $ 1,000,000 DED RETENTION $ $ WORKERS COMPENSATION SPER OTH- YIN - , - - - AND EMPLOYERS' LIABILITY ER ANY PROPRIETOR/PARTNER/EXECUTIVE NHE.L. EACH ACCIDENT $ - - - - (Mandatory n N j EXCLUDED? N I A III E.L. DISEASE - EA EMPLOYEE $ If yes, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT $ DESCRIPTION OF OPERATIONS / LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) City of Ashland is 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 i/ © 1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25 (2014/01) The ACORD name and logo are registered marks of ACORD WNGL390310 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 a Damage To Premises Rented To You - $300,000 N N O Medical Payments Increased Limit - $10,000 Or Amount Shown on Declarations 6 Conditions • Knowledge of Accident, Claim, Suit Or Loss Amended ........................................................6 ° r • Unintentional Failure To Disclose Hazards Waiver of Subrogation .........................................................................................................6 t Bodily Injury Redefined To Include Mental Anguish ..........................................................................6 Insured Contract Amended ..............................................................................................................6 Personal And Advertising Injury Redefined • Televised, Videotaped Or Electronic Publication ..................................................................6 WN GL 39 03 10 Includes copyrighted material of Insurance Services Office, with its permission Page 1 of 6 WNGL390310 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 "Bodily injury" or "property damage" arising out where it is licensed or principally 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 f. (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 age" 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 "auto" you or any contractors or subcontractors (3) Parking an on, or on the ways next to, workin direct or indirect) o premises you own or rent, provided the 9 directly y 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. WN GL 39 03 10 Includes copyrighted material of Insurance Services Office, with its permission Page 2 of 6 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 III - 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), (S) 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 "Personal and advertising injury" arising out of "property damage" to borrowed equipment while not oral, written, televised, videotaped or electronic being used to perform operations at the jobsite. publication of material, if done by or at the Subject to Paragraph 2. of SECTION III - LIMITS direction of the insured with knowledge of its OF INSURANCE, the rules below fix the most we 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 organizations who sustain damages because of AND B 10 11 that "occurrence". We may, or if required by E. Supplementary Payments - Coverages A and B N law, pay all or any part of any deductible 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 thereofl available to the insured time off from work. whether primary, excess, contingent or on any other basis. WN GL 39 03 10 Includes copyrighted material of Insurance Services Office, with its permission Page 3 of 6 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 (1) "Bodily injury" manufacturer, and then repackaged in the or "personal and advertising original container; injuryl: 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 sate 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 other thing or substance by or for the B. Newly Acquired Organizations 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 apply: "property damage" arising out of "your products" 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. 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 WNGL390310 D: Blanket Additional Insured - Lessor Of Leased 2. This insurance does not apply to: Equipment a. "Bodily injury", "property damage" or 1. Section II - 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 II - 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 a to an "occurrence" which takes lace subdivision has issued a permit or authorization in PPIY Y P 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 holes include as an insured any person or organization , driveways, manholes, marquees, hoist away openings, sidewalk. vaults, street banners with whom you have agreed in a written contract, or decorations and executed prior to loss, to name as an additional 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 I11 - LIMITS OF INSURANCE cease to be a tenant in that premises. AMENDMENTS 2. Structural alterations, new construction o; 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: F. Blanket Additional Insured - State Or 6. Subject to Paragraph 5. 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 II - 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 your policy, we will not deny coverage under B. Medical Expense Limit 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 exercise our right of cancellation or pay under Coverage C for all medical expenses non-renewal. because of "bodily injury" sustained by any one 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" done under a written contract, executed prior to loss, SECTION IV -COMMERCIAL GENERAL LIABILITY 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 injuryincludes 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 contract"; To Disclose Hazards 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: k, (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; WN GL 39 03 10 Includes copyrighted material of insurance Services Office, with its permission Page 6 of 6