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HomeMy WebLinkAboutInsurance Certificate: Knife River Materials DATE (MM/DD/YYYY) A- RL7® CERTIFICATE OF LIABILITY INSURANCE 12/27/2016 rHIS 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. PHONE_._ 333 South 7th Street, Suite 1400 A/C _N Ext : ~(A/c No): Minneapolis, MN 55402-2400 E-MAIL Attn: MD U.CertRequest@marsh. com-, Fax: (212) 948-5382 ADDRESS: _ INSURER S) AFFORDING COVERAGE NAIC # J43750-LTMM-GA_WX-17-18 _ 2010 _ 2037 LTMMe Al Y INSURER A_: Liberty Mutual Fire Ins Co 23035 INSURED INSURER B : Associated Electric & Gas Ins Services Ltd 3190004 LTM. Incorporated dba Knife River Mate ials INSURER C : Liberty Insurance Corporation _ 42404 PO Box 1145 INSURER D Medford, OR 97501 - INSURER E : INSURER F : COVERAGES CERTIFICATE NUMBER: CHI-005204108-20 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 ADDL SUBR POLICY EFF POLICY EXP LIMITS LTR TYPE OF INSURANCE POLICY NUMBER MM/DD/YYYY MM/DD/YYYY A X COMMERCIAL GENERAL LIABILITY TB2-641-005097-047 01/01/2017 01101/2018 EACH OCCURRENCE $ 2,000,000 DAMAGE TO CLAIMS-MADE L OCCUR PREM REMISES (Ea occur ence $ -500,000 MED EXP (Any one person) $ 10,000 PERSONAL & ADV INJURY $ 2,000,000 GENT AGGREGATE LIMIT APPLIES PER GENERAL AGGREGATE $ _4,000,000 POLICY X , PE [ ] LOC PRODUCTS - COMP/OP AGG $ 4,000,000 OTHER. J $ A AUTOMOBILE LIABILITY A12-641-005097-057 0110112017 01/01/2018 COMBINED SINGLE LIMIT $ 2,000,000 Ea accident) X ANY AUTO BODILY INJURY (Per person) $ ALL OWNED SCHEDULED _ AUTOS AUTOS BODILY INJURY (Per accident) $ X I X NON-OWNED PROPERTY DAMAGE $ HIRED AUTOS AUTOS Per accident $ B UMBRELLA LIAB XL5063406P 01/01/2017 01101/2018 EACH OCCURRENCE $ 5,000,000 I OCCUR X EXCESS LIAB CLAIMS-MADE AGGREGATE $ 5,000,000 DED RETENTION $ $ A WORKERS COMPENSATION WC2-641-005097-027 (Guar. Cost) 01101/2017 01/0112018 X PER OTH- AND EMPLOYERS' LIABILITY STATUTE ER C Y/N WA7-64D-005097-017 AOS) 01/01/2017 01/0112018 1,000,000 ANY PROPRIETOR/PAR-NER/EXECUTIVE I N/A ( E L EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? (Mandatory in NH) "Includes "Stop-Gap E.L DISEASE - EA EMPLOYEE $ 1,000,000 If yes, describe under 1,000,000 DESCRIPTION OF OPERATIONS below E L. DISEASE - POLICY LIMIT $ DESCRIPTION OF OPERATIOVS / 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: Kari 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 Mukherjee +c~ ra •,•~-+~c-*w, i~ ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25 (2014101) The ACORD name and logo are registered marks of ACORD THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY, NOTICE OF CANCELLATION TO THIRD PARTIES Thy endorsement modifies insuran-G provided under the follo,ving: BUSINESS AUTO COVERAGE PART MOTOR CARRIER COVERAGE PART GARAGE COVERAGE PART TRUCKER COVERAGE DART EXCESS AUTOMOBILE LIABILITY INDFrvINITY COVE kAG PART' SELF-INSURED TRUCKER EX"-'FSS LIABILITY COVERAGE PART COMM R,CIAL GENERAL LIABILIT'Y' COVERAGE DART EXCESS COMMERCIAL GENERAL LIABILITY COVERAGE DART PROD UCT'SiCOMPLETELOPERATIONS LIABILITY COVERAGE PART LIQUOR LIABILITY CO's EWk E PART C01MMER I LIA131LI -Y UMBRELLA COVERACIF FORM - ...,..w.,..,..w.._.,____- .....:...:.v.._~_..._ Schedule _ m _ _ W - - Nerve of Other Person(s) I Email Address or mailing address: Number Days Notice: Per schedule of ce ificat Per schedule of ,ee ficat:e 90 Jholders on file with the file wi h the Company, 1 } f If vfi tr is policy :0 ary reason € tl r than o E of p sir rt , will notify t e- a or organizations shown in the Schedule above. W wil! send riot c(: to the, iawai or fnail in a address listed above at least 10 days or the nir ber of days listed above, it any, before the c:ancellalion be-comes effective In no evert dries the notice to the third pxty exceed the notice to the fast narned inns,,red- TF,is adiv vc e notifir.aLion 3~f a pending g race4 Lion of cove-rage i i:ntcnded as a courtesy only Ow f~ tor e to provide such advance notification will no, extend the policy ncell ation date nor negate of the policy. All other tera-is a~ld c oriditions of fi I'S poky remain unchanged. LIM 99 01 05 11 1) 2011 Liberty Mutual GrOdp Of COMpanl s: Al r.ghts reserved, P.': qe 1 0f 1 Includes copy' Shied rnplerial of Insurance Ser". ces ace, no,, w tYa is permissl0r). P01_1GY r UME3=R; 1 ~ 1 t: t ~s ~tx t sY COMMERCIAL AUTO 0 20 48 10 13 THIS ENDORSEMENT CHANGES THE POLICY. LE. READ IT CAREFULLY, DESIGNATED INSURED FOR COVERED AUTOS LIABILITY COVERAGE F his c,,ndf r; en.-,rk°nt rnu € e, 'v ~:Lrrarrr: e provided uncer the foilo;dong. AUTO DEALERS COVERAGE FORM MOTOR CARRIER COVLFAGE FORNI vWi respect te cowarage providec by endorsc;rnc'nt' t~ie c;f the Coverage Forni apply unless This en on-:?cnient identifies pe'r,,, Ns) or or ruz trcnls' v,,, o are "r)6ureds' for Covered Altos Li bi'lily C.overage uncle,' tile 01[10 is An lr;s rert provision, of th x overa c Fc)rrn, This eldorsen-wrot does n Iter covrara:, prov c_ d i -i the Coverage F.,-)rm, SCHEDULE Na€n Person(s) Or Organ izat ion(s), : Any p roan car" d:i<~gr:`~>"8€zati Jn wh..cm you have s3~:~t"eed in vvr~ :t~ (63 to add as aaa, n additional insured, b''lJ on"y to coveracie cnnd ?-f,. im urn :iwtit'; of fit`€suran,":"E" required -v this,%tritteri aoCep; vierit ands in no event to exceed ekher i T,rii~n olid;y will be primary arm to any ::ke ins i7aricca va;lab1e, to the person oror(a nota,°d attc,,i,e Inforr ation reouir d to ~r t tl i t d ale, it got <Ibcwe will be sho'> n ir° the 7,eclaratrr~ns. Each person c,° or9cani!zation shown W, the Schedule ;,s ter.; 8iir3 ~ :rred' fo- Covered Autos Liability Cov, v , 9 , i~i_#t only to tho clixter?t that person or organ i ation qualifir as ar. `insured" under t.,,e Who Is An Insured Covered Au-.tos Liabiiitm Cove-raci in the bus:, css Autc: av Motor Carr r Coveregea Forims and Para rai e of uti4 r t Co'vered Auto,-, CA 20 48 10 1 nsuranco- w a e<, t 3tf:~: ~ lr> 2011 Page 011 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 Additional Insured Person(s) Location(s) Of Covered Operations Or Organization(s): Any persons or organizations for whom you have All locations as required in writing and agreed to agreed in writing, prior to an "occurrence" or prior to an "occurrence" or offense. "offense" to provide additional insured status, and specifically requiring this version of the endorsement. Information required to complete this Schedule, if not shown above, will be shown in the Declarations. A. Section Il - Who Is An Insured is amended to B. With respect to the insurance afforded to these include as an additional insured the person(s) or additional insureds; the following additional exclu- organization(s) shown in the Schedule, but only sions apply: with respect to liability for "bodily injury" "property This insurance does not apply to "bodily injury' or damage" or "personal and advertising injury" "property damage" occurring after: caused, in whole or in part, by: 1. All work, including materials, parts or equip- 1. Your acts or omissions; or ment furnished in connection with such work, 2. The acts or omissions of those acting on your on the project (other than service, maintenance behalf; or repairs) to be performed by or on behalf of in the performance of your ongoing operations for the additional insured(s) at the location of the the additional insured(s) at the location(s) desig- covered operations has been completed: or nated above. CG 2010 07 04 c,) ISO Properties, Inc., 2004 Page 1 of 2 2. That portion of "your work" out of -which the injury or damage arises has been put to its in- tended use by any person or organization other than another contractor or subcontractor en- gaged in performing operations for a principal as a part of the same project. This endorsement is executed hythe LIBERTY MUTUAL FIRE IN SURANCE COMPANY Preen iu:n $ Effective Date 0110112017 Expiration Date 01101}2018 For attachment to Policy No T11321-641-005097 047 Audit Basis Issued To Countersigned by Authorized Representative Issued Sales Office and No. End. Serial No. Page 2 of 2 ISO Properties, Inc,, 2004 CG 20 10 07 04 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE DEAD IT CAREFULLY. ADDITIONAL.INSURED OWNERS, LESSEES OR CONTRACTORS - COMPLETED OPERATIONS This endorsement modifies insurance provided under the fallowing: COMMERCIAL GENLRAL LIABILITY COVERAGE PART SCHEDULE - - Name Of Additional insured Person(s) Location And Description Of Completed Operations Or Organization(s): Any persons or organizations for whom you have All locations as required in writing, and agreed to agreed in writing, prior to an "occurrence" or prior to an "occurrenw- " or offense. "offense", to provide additional insured status, and specifically requiring this version of the endorse- ment. Information required to complete this Schedule, if not shown above will be shown in the Declarations. Section If - 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 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-cornpleted operations hazard". This endorsement is executed by the LIBERTY MUTUAL FIRE INSURANCE COMPANY Premium $ Effective Date Expiration Date For attactirnent to Policy No. T132-641-005007-047 Audit Bans Issued To Countersigned by Authxized Representative Issued Sales Office and No. End. Serial No. CG 20 37 07 04 0 ISO Properties, Inc., 200 Page 1 of 1 Policy Number T112-641-005097-047 Issued by LIBERTY MUTUAL FIRE INSURANCE CONIPANY THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. NOTICE OF CANCELLATION TO THIRD PARTIES This endorsement modifies insurance pro\,Ided 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) f Email Address or mailing address: Number Days Notice: Organizations): Per Schedule of certificate 90 holders on file with the Company } i 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 0105 11 (C', 2011 Liberty Mutual Group of Companies. All rights reserved. Page 1 of 1 Includes copyrighted material of Insurance Services Office. Inc., with its permission. NOTICE ( EL LA 10170 TIARC PARTIES if xa fi.;.Vlcel INS poky kp yy u` f ?e~sa~x 5~.ya ~ rR3$.:r 1i C€ 2 S`,." co ; ,y p' f~, any y4 ~3,t'-~"€:' tr +{~s . ~ of 5 ~f ~ 3~a3i a ~r ..s ,.#-r~< LI'<'. f h : akik: be'.o<r, ~ 4~;! vvi l axrjr:O 2 #:;e l M€' e£'iaC:' 8', "€aikIg adYew;" 1~w? ~~ouv" at x as r;P. bem re ~`z€' a`'E'E` t be== iir&;6:•E'k$: i €su eveni pandmg € r o t bwage wi.'ndu'.d as a >";.,:v.d€ne'xy .;x Our Wh:av k% provide 5~'.Ch § AA P#xwy Name o Other person(s) Email Address or madir€ a re- ` f wmher Days Notice. Organization(s) Per scWdu tY cg i' i . id a e Per a'che6k€sl£ of " irrHL Isar,-: romparly befaw"I TiY.9 C 9 0 75y a~10 20161 . Wery aR wa he w-am?; Pop 1 1. 2 A, its i¢ : n # > .`r my v snow i3:€ M An ,'rW a nobly >n f Y in t ScY, , ~-vlh Us.n d mcames eRecove in no even' Cue the `"Ede i:E,,. , AM pa mr.: c,' d c''." nc4 ,,z,. v-- o- nzv--n&d §!iri, fir. u dv~ at#`we n;.?.tff..,.at€w" o 11 p,,1E;c.Er a.. :3 .o"ea o . of c>. vF f n is , pwovide Such ,.efi... 0 s.TN..... ':'F ..a:`•3 extend tY.e f. .iz...y Schedule Namf" OP. Offi % - Perso m) j .E aII A, d SS w nai1in add evast Nlombe~ Day"""7 TO- s t: Dam x d 50971-017 ~,4.... a 1.. P42. iif VVc 99 2.i] ?S 1 Ed 12&0210-,