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HomeMy WebLinkAboutInsurance Certificate: Pilot Rock Excavation (2) DATE (MM/DD/YYY) A!~°® CERTIFICATE OF LIABILITY INSURANCE 8/16/2016 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 have ADDITIONAL INSURED provisions or 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 NAME: Kristi R Dolmage Hart Insurance Agency PHONE FAX PO Box 1240 A/C No Ext: (541) 779-4232 A/C No: (541) 772-3963 E-MAIL Grants Pass OR 97528 ADDRESS: INSURERS AFFORDING COVERAGE NAIC # INSURER A: Berkley Assurance Company INSURED (541) 779-4916 INSURER B: The Burlington Insurance Compa Pilot Rock Excavation Inc INSURER C : SAIF Corporation 36196 5 S Stage Rd INSURER D: Mutual of Enumclaw Insurance C 14761 Medford OR 97 501 INSURER E : INSURER F : COVERAGES CERTIFICATE NUMBER: Cert ID 712 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 ADDLSUBR POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSD POLICY NUMBER MM/DD/YYYY MM/DDIY YY LIMITS A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 11000,000 CLAIMS-MADE FxIOCCUR Y VUMB0120900 7 0/2 016 7 0 017 PREMIES( RENTED /2 /2 /2 PREMISES Ea occurrence $ 100,000 MED EXP (Any one person) $ excluded PERSONAL & ADV INJURY $ 11000,000 GENT AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 POLICY F-1 PRO F7 LOC PRODUCTS -COMP/OP AGG $ 2,000,000 JECT OTHER: Empl Benefits Liab $ 1,000,000 AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ Ea accident 1,000,000 D X ANY AUTO CPP0020963 7/20/2016 7/20/2017 BODILY INJURY (Per person) $ OWNED SCHEDULED BODILY INJURY (Per accident) $ AUTOS ONLY AUTOS HIRED NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY AUTOS ONLY Per accident B UMBRELLA LIAB X OCCUR HFF0003743 ,7/20/2016 7/20/2017 EACH OCCURRENCE $ 4,000,000 EXCESS LIAR CLAIMS-MADE AGGREGATE $ 4,000,000 DED X RETENTION $ 0 $ PER C AND EMPSLOYYERSERS'' LIABILITY AYIN 784439 9/1/2016 9/1/2017 X STATUTE EERH AND EMP ANYPROPRIETOR/PARTNER/EXECUTIVE ❑ E.L. EACH ACCIDENT $ 500,000 OFFICER/MEMBER EXCLUDED? N/A (Mandatory in NH) E.L. DISEASE - EA EMPLOYEE $ 500 , 000 If yes, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE -POLICY LIMIT $ 500 , 000 $ I $ DESCRIPTION OF OPERATIONS / LOCATIONS /VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) Additional insured forms CG2033,CG2037, Waiver CG2404 attached City of Ashland and its employees, officers and agents are included as additional insured as respects to general liability and auto liability. Project: Alley Extension - N Main to Lori Lane CERTIFICATE HOLDER CANCELLATION 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 AUTHORIZED REPRESENTATIVE Ashland OR 97520 ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD Page 1 of 1 COMMERCIAL GENERAL LIABILITY CG 20 33 07 04 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - OWNERS, LESSEES OR CONTRACTORS - AUTOMATIC STATUS WHEN REQUIRED IN CONSTRUCTION AGREEMENT WITH YOU This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART A. Section If - Who Is An Insured is amended to B. With respect to the insurance afforded to these include as an additional insured any person or additional insureds, the following additional organization for whom you are performing exclusions apply. operations when you and such person or This insurance does not apply to, organization have agreed in writing in a contract or agreement that such person or organization be 1. "Bodily injury", "property damage" or "personal added as an additional insured on your policy. and advertising injury" arising out of the Such person or organization is an additional rendering of or the failure to render, any insured only with respect to liability for "bodily professional architectural, engineering or injury", "property damage" or "personal and surveying services, including: advertising injury" caused, in whole or in part, by: a. The preparing, approving, or failing to 1. Your acts or omissions; or prepare or approve, maps, shop drawings, 2. The acts or omissions of those acting on your opinions, reports, surveys, field orders, behalf; change orders or drawings and specifications; or in the performance of your ongoing operations for b. Supervisory, inspection, architectural or the additional insured. engineering activities. A person's or organization's status as an 2. "Bodily injury" or "property damage" occurring additional insured under this endorsement ends after: when your operations for that additional insured are completed. a. All work, including materials, parts or equipment furnished in connection with such work, on the project (other than service, maintenance or repairs) to be performed by or on behalf of the additional insured(s) at the location of the covered operations has been completed; or b. 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 contractor or subcontractor engaged in performing operations for a principal as a part of the same project. CG 20 33 07 04 0 ISO Properties, Inc., 2004 Page 1 of 1 ❑ 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 LIABILITY COVERAGE PART SCHEDULE Name Of Additional Insured Person(s) Or Organization(s): Location And Description Of Completed Operations As required by written contract executed prior to As required by written contract executed prior to the date of occurrence date of occurrence but only to the extent permitted by law and the insurance afforded to such additional insured will not be broader than that which you are required by the contract or agreement to provide for such additional insured. Construction project sites at which you performed work for such additional insured. Information required to complete this Schedule, if not shown above, will be shown in the Declarations. 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 "property damage" caused, in whole or in part, by "your work" at the location designated and described in the schedule of this endorsement performed for that additional insured and included in the "products- completed operations hazard". CG 20 37 07 04 © ISO Properties, Inc., 2004 Page 1 of 1 ❑ THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. WAIVER OF TRANSFER OF RIGHTS OF RECOVERY AGAINST OTHERS TO US This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Name of Person or Organization: As required by written contract executed prior to date of occurrence (If no entry appears above, information required to complete this endorsement will be shown in the Declarations as applicable to this endorsement.) The TRANSFER OF RIGHTS OF RECOVERY AGAINST OTHERS TO US Condition (Section IV- COMMERCIAL GENERAL LIABILITY CONDITIONS) is amended by the addition of the following.. We waive any right of recovery we may have against the person or organization shown in the Schedule above because of payments we make for injury or damage arising out of your ongoing operations or "your work" done under a contract with that person or organization and included in the "products-completed operations hazard". This waiver applies only to the person or organization shown in the Schedule above. CG 24 04 10 93 Copyright, Insurance Services Office, Inc., 1992 Page 1 of 1 ❑