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HomeMy WebLinkAboutInsurance Certificate: LTM, Incorporated ' 7 ® DATE (MM/DD/YYYY) AC4Z CERTIFICATE OF LIABILITY INSURANCE 12/22/2017 li.~ 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 Marsh USA Inc WAME:_ PHONE FAX 333 South 7th Street, Suite 1400 C, No. Ext): A/C No): Minneapolis, MN 55402-2400 E-MAIL Attn: MDU.CertRequest@marsh.com; Fax: (212) 948-5382 ADDRESS: _ INSURERS AFFORDING COVERAGE NAIC N 143750-LTMM-GAWX-11-19 2010 2037 LTMMe AI Y INSURER A : Liberty Mutual Fire Ins Co 23035 INSURED 3190004 LTM, Incorporated INSURER B: Associated Electric & Gas Ins Services Ltd dba Knife River Materials INSURER C :Liberty Insurance Co orahon 42404 PO Box 1145 Medford, OR 97501 INSURER D INSURER E : INSURER F: COVERAGES CERTIFICATE NUMBER: CHI-007946941-22 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 NOTWI7 HSTANDING 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 SU POLICY EFF POLICY EXP LIMITS LTR TYPE OF INSURANCE POLICY NUMBER MMIDD/YYYY MMIDD/YYYY A X COMMERCIAL GENERAL LIABILITY 762.641-005097-048 01/01/2018 01/01/2019 EACH OCCURRENCE $ 2,000,000 -vi AMAX E TO RENTED CLAIMS-MADE OCCUR PREMISES Ea occurrence $ 500,000 MED EXP (Any one person) $ 10,000 PERSONAL & ADV INJURY $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER GENERAL AGGREGATE $ 4,000,000 PRODUCTS - COMPIOP AGG $ 4,000,000 I - POLICY JECOT LOC OTHER $ A A12-641-005097-058 01/01/2018 01/0112019 COMBINED SINGLE LIMIT $ 2,000,000' AUTOMOBILE LIABILITY Ea accident X I ANY AUTO BODILY INJURY (Per person) $ OWNED I SCHEDULED BODILY INJURY (Per accident) $ AUTOS ONLY AUTOS X HIRED X NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY AUTOS ONLY Per accident _ UM IRELLALIAB XL5063407P 01/0112018 01/01/2019 5,000,000 OCCUR EACH OCCURRENCE $ X EXCESS LIAR X CLAIMS-MADE AGGREGATE $ 5,000,000 OF -1 BETE NT10N$ $ A WORKERS COMPENSATION WC2-641-005097-028 (Guar. Cost) 01/01/2018 01101/2019 X PER OTH- AND EMPLOYERS' LIABILITY STATUrE ER C Y I N WA7-64D-005097-018 (AOS) 01101/2018 01!0112019 1,000,000 ANYPRO OFFIC RPMEMBEREXCLUDED?ECUTIVE H] NIA CL EACH ACCIDENT $ (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 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 cumpleted operations, automobile liability, and employers liability. CERTIFICATE HOLDER CANCELLATION City of Ashland SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Attn: Karl 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 Mukherjpe _Mauao►.~ ~D4 Cwa~~ e x ©1988-2016 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. NOTICE OF CANCELLATION ENDORSEMENT This endorsement modifies insurance provided under the following: BUSINESS AUTO COVERAGE FORM GARAGE COVERAGE FORM MOTOR CARRIER COVERAGE FORM TRUCKERS COVERAGE FORM With respect to coverage provided by this endorsement, the provisions of the Coverage Form apply unless modified bythis endorsement. We will not cancel this policy or make changes that reduce the insurance afforded by this policy until written notice of cancellation or reduction has been mailed or delivered to those listed in the schedule below at least; a) 10 days before the effective date of cancellation, if we cancel for non-payment of premium; or b) 9 days before the effective date of the cancellation or reduction if we cancel or reduce the insurance afforded by this policy for any other reason. NAME ADDRESS MDU Resources Group, Inc./ P.O. Box 5650 Centinennial Engery Holdings, Inc. Bismarck, ND 58506-5650 AM 02 0106 10 © 2010, Liberty Mutual Group of Companies. All rights reserved. Page 1 of 1 POLICY NUMBER: A12-641-005097-058 COMMERCIAL AUTO CA 20481013 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. DESIGNATED INSURED FOR COVERED AUTOS LIABILITY COVERAGE This endorsement modifies insurance provided under the following: AUTO DEALERS COVERAGE FORM BUSINESS AUTO COVERAGE FORM MOTOR CARRIER COVERAGE FORM With respect to coverage provided by this endorsement, the provisions of the Coverage Form apply unless modified by this endorsement. This endorsement identifies person(s) or organization(s) who are "insureds" for Covered Autos Liability Coverage under the Who Is An Insured provision of the Coverage Form. This endorsement does not alter coverage provided in the Coverage Form. SCHEDULE Name Of Person(s) Or Organization(s): Any person or organization whom you have agreed in writing to add as an additional insured, but only to coverage and minimum limits of insurance required by the written agreement, and in no event to exceed either the scope of coverage or the limits of insurance provided in this policy. This policy will be primary and non-contributory to any like insurance available to the person or organization noted above. Information required to complete this Schedule, if not shown above, will be shown in the Declarations. Each person or organization shown in the Schedule is an "insured" for Covered Autos Liability Coverage, but only to the extent that person or organization qualifies as an "insured" under the Who Is An Insured provision contained in Paragraph A.I. of Section II - Covered Autos Liability Coverage in the Business Auto and Motor Carrier Coverage Forms and Paragraph D.2. of Section I - Covered Autos Coverages of the Auto Dealers Coverage Form. CA 20 4810 13 0- Insurance Services Office, Inc., 2011 Page 1 of 1 POLICY NUMBER: TB2-641-006097-04$ COMMERCIAL GENERAL LIABILITY CG 20100413 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 A. Section If - Who Is An Insured is amended to 1. All work, including materials, parts or equipment include as an additional insured the person(s) or furnished in connection with such work, on the organization(s) shown in the Schedule, but only project (other than service, maintenance or with respect to liability for "bodily injury", "property repairs) to be performed by or on behalf of the damage" or "personal and advertising injury" additional insured(s) at the location of the caused, in whole or in part, by: covered operations has been completed; or 1. Your acts or omissions; or 2. That portion of "your work" out of which the 2. The acts or omissions of those acting on your injury or damage arises has been put to its behalf; intended use by any person or organization other than another contractor or subcontractor in the performance of your ongoing operations for engaged in performing operations for a principal the additional insured(s) at the loeatlon(s) as a part of the same project. designated above. C. With respect to the insurance afforded to these However: additional insureds, the following is added to 1. The insurance afforded to such additional Section III - Limits Of Insurance: insured only applies to the extent permitted by If coverage provided to the additional insured is law; and required by a contract or agreement, the most we 2. If coverage provided to the additional insured is will pay on behatf of the additional insured is the required by a contract or agreement, the amount of insurance: Insurance afforded to such additional insured I. Reguiired by the contract or agreement; or will not be broader than that which you are required by the contract or agreement to provide 2• Available under the applicable Limits Of for such addhionai Insured. Insurance shown in the Declarations; S. With respect to the insurance afforded to these whichever Is less. additional insureds, the following additional This endorsement shall not increase the applicable exclusions apply; Limits of Insurance shown In the Declaration. This insurance does not apply to "bodily injury" or "property damage" occurring meter: CG 2010 0413 ©160 Properties, Inc., 2012 Page 1 of 2 C] I SCHEDULE Name Of Additions! Insured Parson{s} Or Organization(s) Locations Of Covered: Operations All persons or organizations for whom you have All locations as required by a written contract or entered into a written contract or agreement, prior to agreement entered into prior to an "occurrence" an "occurrence" or offense, to provide additional or offense. insured status. i Information required to complete this Schedule, if not shown above will be shown in the Declarations. CG 2010 0413 ® Insurance Services Oifi, inc., 2012 Page 2 of 2 I I POLICY NUMBER: TB2-641-005097-048 COMMERCL4L GENERAL LIABILITY CG20370413 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 PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE PART SCHEDULE Name Of Additional Insured Peraon(s) Or Organizatiun s Location And Description Of Conn Ietad O ations All persons or organizations for whom you have All locations as required by a written contract or entered into a written contractor agreement, prior agreement centered Into prior to an "occurrence" or to an "occurrence" or offense, to provide additional offense. insured status. Information required to complete this Schedule, if not shown above, will be shown in the Declarations. A. Section II Who Is An Insured is amended to B. With respect to the insuranoe afforded to these include as an additional insured the person(s) or additional insureds, the folloWng Is added to organization(s) shown in the Schedule, but only Section III - Limits Of Insurance; with respect to liability for "bodily injury" or If coverage provided to the additional insured is property damage" caused, in whole or in part, by required by a contract or agreement, the most we "your work at the location designated and will pay on behalf of the additional insured is the described in the Schedule of this endorsement amount of insurance: performed for that additional insured and included in the "products-completed operations 1. Required by the contract or agreement; or hazard". 2. Available under the applicable Limits of However; Insurance shown In the Declarations; 1. The Insurance afforded to such additional whichever Is less. insured only applies to the extent permitted This endorsement shall not increase the applicable by law; and Limits of Insurance shown in the Declarations. 2. If coverage provided to the additional insured is required by a contract or agreement, the insurance afforded to such additional insured will not be broader than that which you are ; required by the contract or agreement to P.;.. provide for such additional insured. CG 20 37 0413 0 Insurance Services Office, Inc., 2012 Page 1 of 1 Policy Number T82-641-005097-048 Issued by LIR.ERTY MUTUAL FIRE INSURANCE COMPANY THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. NOTICE OF CANCELLATION TO THIIRD PARTIES This endorsement modifies insurance provided 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 tdame of Other Person(s)1 Emall Address or mailing address: ! Number Days Notice: Organization(s): Per Schedule of certificate 90 holders or, file with the Comfy I i E 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 notloe 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 fiailure 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. r LIM 99 01 035 11 0 2011 Liberty Mutual Group of Companies. All rights reserved. Page 1 of 1 Includes copyrighted material of Insurance Services Office, Inc., with its permission. THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. NOTICE OF CANCELLATION TO THIRD PARTIES 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 below. We will send notice to the email or mailing address listed below at least 10 days, or the number of days listed below, if any, before cancellation becomes effective. In no event does the notice to the third party exceed the notice to the first named insured. & 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. SCHEDULE Name of Other Person(s) 1 Email Address or mailing address: Number Days Notice: Organization(s): Per schedule of certificate Per schedule of certificate 90 holders on file with the holders on file with the company company All other terms and conditions of this policy remain unchanged. A Issued by Liberty Insurance Corporation 21814 For attachment to Policy No. WA7-64D-005097-018 Effective Date Premium $ Issued to Centennial Energy Holdings. Inc. WC 99 20 75 v 2016 Liberty Mutual Insurance Page 1 of 1 Ed. 1210112016 I THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. NOTICE OF CANCELLATION TO THIRD PARTIES 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 below. We will send notice to the email or mailing address listed below at least 10 days, or the number of days listed below, if any, before 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. SCHEDULE Name of Other Person(s) / Email Address or mailing address: Number Days Notice: Organization(s): Per schedule of certificate Per schedule of certificate 90 holders on file with the holders on file with the company company All other terms and conditions of this policy remain unchanged. a 'I G Issued by Liberty Mutual Fire Insurance Company 16586 For attachment to Policy No. WC2-641-005087-028 Effective Date Premium S Issued to MDU Resources Group, Inc. WC 99 20 75 v 2016 Liberty Mutual Insurance Page 1 of 1 Ed. 12101/2016 0001939 SP 0804 -C01-P01939-1 City of Ashland Attn: Kari Olsen 90 N. Mountain Ashland, OR 97520