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HomeMy WebLinkAboutInsurance Certificate: Pacific Paving Inc Client: 176077 PACIPAVI2 ~~C~D~ CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDDIYYYY) 311012017 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 NAMEACT Nikki Russell Propel Insurance PHONE g00 499-0933 FAx 866 577-1326 Medford Commercial Insurance E•MAILo Ext : Alt, No ADDRESS: nikkl.russell@propelinsurance.com P 0 Box 936 Medford, OR 97501 INSURER(S) AFFORDING COVERAGE NAIC # INSURERA: Western National Assurance Comp 24465 INSURED INSURER B :Western National Insurance Grou Pacific Paving, Inc PO Box 2370 INSURER C INSURER D White City, OR 97503 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. NOTIMTHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACTOR 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. LIMITS TYPE OF INSURANCE NSRL WVD POLICY NUMBER MMlDIDY~ M~LDDYl1'YXYY A COMMERCIAL GENERAL LIABILITY CPP107021804 312012017 03120/201 EACH OCCURRENCE $1 000 000 CLAIMS-MADE ~X OCCUR PREMISES Ea occu ante $300 OOO MED EXP (Any one person) $1 O OOO PERSONAL & ADV INJURY $1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 X POLICY ~ JECT ~ LOC PRODUCTS -COMP/OP AGG $2,000,000 OTHER; $ A AUTOMOBILE LIABILITY CPP106912804 312012017 031201201 COMBINED SINGLE LIMIT Ea accident $1,000,000 ANY AUTO BODILY INJURY (Per person) $ ALL OWNED X SCHEDULED BODILY INJURY (Per accident) $ AUTOS AUTOS X HIRED AUTOS X NON-0WNED PROPERTY DAMAGE $ AUTOS Per accident B UMBRELLA LIAB X OCCUR UMB101591303 312012017 031201201 EACH OCCURRENCE $1 OOO 000 EXCESS LIAR CLAIMS-MADE AGGREGATE $1 000 000 DED X RETENTION $1 OOOO $ WORKERS COMPENSATION PER OTH- ANDEMPLOYERS' LIABILITY ANY PROPRIETORlPARTNER/EXECUTIVE Y! N E.L. EACH ACCIDENT $ OFFICERIMEMBER EXCLUDED? ❑ N 1 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 I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) City of Ashland is hereby named as additional insured per Endorsement CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOV E C City of Ashland E D S RIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Kari Olson Purchasing Rep ACCORDANCE WITH THE POLICY PROVISIONS. 90 N. Mountain Ave. Ashland, OR 97520-2014 AUTHORIZED REPRESENTATIVE ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25 (2014!01) 1 of 1 The ACORD name and logo are registered marks of ACORD #S26182151M2618097 LAB00 COMMERCIAL GENERAL LIABILITY WN GL 49 0715 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED -OWNERS, LESSEES OR', CONTRACTORS -AUTOMATIC STATUS WHEN REQUIRED IN CONSTRUCTION AGREEMENT WITH 1f0U PRIMARY AND NONCONTRIBUTORY This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART A. Section II -Who Is An Insured is amended to B• With respect to the insurance afforded to these include as an additional insured any person or or- additional insureds, the following additional exclu- ganization for whom you are performing opera- sion applies: tions when you and such person or organization This insurance does not apply to: have agreed in writing in a contract or agreement 1. "Bodily injury", "property damage" or "personal that such person or organization be added as an and advertising injury" arising out of the ren- additional insured on your policy. Such person or Bering of, or the failure to render, any profes- organization is an additional insured only with re- sional architectural, engineering or surveying spect to liability for "bodily injury", "property dam- services, including: age" or "personal and advertising injury" caused, a. The preparing, approving, or failing to pre- inwhole or In part, by. pare or approve, maps, shop drawings, 1. Your acts or omissions; or opinions, reports, surveys, field orders, 2. The acts or omissions of those acting on your change orders or drawings and specifica- behalf; tions; 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 additional This exclusion applies even if the claims insured under this endorsement ends when your against an additional insured allege negli- operations for that additional insured are complet- gence or other wrongdoing in the supervision, ed. hiring, employment, training or monitoring of However: others by that insured, if the "occurrence" 1. The insurance afforded to such additional in- which caused the "bodily injury" or "property sured only applies to the extent permitted by damage , or the offense which caused the law; and "personal and advertising injury", involved the rendering of or failure to render any profes- 2. If coverage provided to the additional insured sional services by you with respect to your is required by a contract or agreement, the in- providing engineering, architectural or survey- surance afforded to such additional insured ing services in your capacity as an engineer, will not be broader than that which you are re- architect or surveyor. quired by the contract or agreement to provide for such additional insured. WN GL 49 0715 Page 1 of 2 Includes copyrighted material of Insurance Services Office, Inc., with its permission. WN CA 27 0616 BUSINESS AUTO ENHANCEMENT ENDORSEMENT The Business Auto 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 SAGE Accidental Airbag Deployment Coverage Auto LoanlLease Gap Coverage 4 Blanket Additional Insured 2 Blanket Waiver of Subrogation 5 Broadened Definition of Insured includes: Newly Acquired Organizations for up to 180 Days 2 Employees as Insureds 2 Subsidiaries in Which You Own 50% or More 2 Deductible Waiver for Glass Repair 3 Employee Hired Auto 2, 5 Fellow Employee Coverage 3 Hired Auto Physical Damage Coverage 4 Knowledge of Accident, Claim, Suitor Loss 5 Loss Of Use Expenses -Amended 3 Personal Effects 3 Rental Reimbursement Coverage 4 Supplementary Payments -Amended: Bail Bonds up to $5,000 2 Loss of Earnings up to $5001Day ~ Transportation Expense Limits -Amended 3 Unintentional Failure to Disclose Hazards 5 WN CA 27 06 16 Includes copyrighted material of Insurance Services Office, Inc., with its permission. Page 1 of 5 D. Fellow Employee Coverage D. Glass Repair -Deductible Waiver SECTION II -COVERED AUTOS LIABILITY SECTION III - PHYSICAL DAMAGE COVERAGE, B. Exclusions, 5. Fellow COVERAGE, A. Coverage, 3. Glass Breakage - Employee, the following is added: Hitting A Bird Or Animal -Falling Objects Or Missiles, is amended by adding the following: Co-Employee Lawsuit Defense Cost Reimbursement No deductible will apply to glass breakage if such glass is repaired, in a manner acceptable to us, If a suit seeking damages for "bodily injury" to any rather than replaced. fellow "employee" of the "insured" arising out of and in the course of the fellow "employee's" E. Hired Auto Physical Damage employment or while performing duties related to the conduct of your business, or a suit seeking SECTION III - PHYSICAL DAMAGE damages brought by the spouse, child, parent, COVERAGE, A. Coverage is amended by adding brother or sister of that fellow "employee", is the following: brought against you, we will reimburse reasonable 5. Hired Auto Physical Damage costs that you incur in the defense of such matters. Any reimbursement made pursuant to If hired "autos" are covered "autos"'for Liability this sub-section will be in addition to the limits of Coverage and if Comprehensive, Specified liability set forth in the Declarations. Causes of Loss, or Collision coverages are provided under this coverage form for any "auto" you own, then the Physical Damage SECTION III -PHYSICAL DAMAGE COVERAGE Coverages provided are extended to "autos" AMENDMENTS you hire of like kind and use, subject to the A. Transportation Expense -Limits Amended following: SECTION III - PHYSICAL DAMAGE a. The most we will pay for any one "loss" is COVERAGE, A. Coverage, 4. Coverage $50,000 or the actual cash value or cost to Extensions, a. Transportation Expenses is repair or replace, whichever is less, minus a deductible; amended by replacing $20 per day/$600 maximum limit with $50 per day/$1000 maximum. b. The deductible will be equal to the largest deductible applicable to any owned "auto" B. Hired Auto Physical Damage -Loss Of Use for that coverage. Any Comprehensive Expenses -Limits Amended deductible does not apply to "loss" caused by fire or lightening; SECTION III - PHYSICAL DAMAGE COVERAGE, A. Coverage, 4. Coverage c. Hired Auto Physical Damage coverage is Extensions, b. Loss of Use Expenses is excess over any other collectible amended by replacing the $20 per dayl$600 insurance; and maximum limit with $50 per day/$750 maximum limit. d. Subject to the above limit, deductible and excess provisions we will provide C. Personal Effects Coverage coverage equal to the broadest coverage applicable to any covered "auto" you own. SECTION III - PHYSICAL DAMAGE COVERAGE, A. Coverage, 4. Coverage If a limit for Hired Auto Physical Damage is Extensions is amended by adding the following: indicated in the Declarations, then that limit replaces, and is not added to, the $50,000 limit c. Personal Effects indicated above. We will pay up to $500 for "loss" to personal effects, which are: Owned by an "insured"; and (2) In or on your covered "auto." This coverage applies only in the event of the total theft of your covered "auto." No deductible applies to this coverage WN CA 27 06 16 Includes copyrighted material of Insurance Services Office, Inc., with its permission. Page 3 of 5 SECTION IV -BUSINESS AUTO CONDITIONS C. Unintentional Failure to Disclose Hazards AMENDMENTS SECTION IV -BUSINESS AUTO CONDITIONS A. Duties In The Event Of Accident, Claim, Suit Or B. General Conditions, 2. Concealment, Loss Amended Misrepresentation Or Fraud, is amended by SECTION IV -BUSINESS AUTO CONDITIONS, adding the following paragraph: A. Loss Conditions, 2. Duties In The Event Of If you unintentionally fail to disclose any hazards Accident, Claim, Suit Or Loss, a. is amended by existing at the inception date of the policy, or adding the following: during the policy period in connection with any This condition applies only when the "accident" or additional hazards, we will not deny coverage "loss" is known to: under this Coverage Part because of such failure. (1) You, if you are an individual; D. Employee Hired Auto (2) A partner, if you are a partnership; SECTION IV -BUSINESS AUTO CONDITIONS, B. General Conditions, 5. Other Insurance, (3) An executive officer or insurance manager, if paragraph b. is deleted and replace by the you are a corporation; or following: (4) A member or manager, if you are a limited b. For Hired Auto Physical Damage Coverage, liability company. the following are deemed to be a covered "autos" you own: But, this section does not amend the provisions relating to notification of police, protection or (1) Any covered "auto" you lease, hire, rent or examination of the property which was subject to borrow. the "loss". (2) Any covered "auto" hired or rented by your B. Blanket Waiver of Subrogation "employee" under a contract in that individual "employee's" name, with your Section IV -BUSINESS AUTO CONDITIONS, A. permission, while performing duties related Loss Conditions, 5. Transfer of Rights of to the conduct of your business. Recovery Against Others to Us, is amended by adding the following exception: However, any "auto" that is leased, hired, rented or borrowed with a driver is not a However, we waive any right of recovery we may covered "auto". have against any person or organization to the extent required of you by a written contract signed and executed prior to any "accident" or "loss", provided that the "accidenf' or "loss" arises out of operations contemplated by such contract. The waiver applies only to the person or organization designated in such contract. WN CA 27 06 16 Includes copyrighted material of Insurance Services office, Inc., with its permission. Page 5 of 5