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HomeMy WebLinkAboutInsurance Certificate: Canyon Industries Inc., Canyon Hydro Client#: 1925347 CANYOIND ACORD,. CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) 2/24/2022 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 thiscertificate does not confer any rights to the certificate:holder in lieu of such endorsement(s). PRODUCER CONTACT Danielle Neumann NAME:TA USI Insurance Services NW PHONE 509 606-0271 FAX No): 509 456-3432 (A/C,No,Ext): 9016 E.Indiana Ave.,Suite A aonRess: danielle.neumann@usi.com Spokane Valley,WA 99212 INSURER(S)AFFORDING COVERAGE NAIL# 509 456-2648 INSURER A:AIG Specialty Insurance Company 26883 INSURED INSURER B:Lloyd's of London SURPLU • Canyon Industries,Inc.,Canyon Hydro INSURER C:AGCS Marine Insurance Company 22837 PO Box 36 INSURER D:National Union Fire Ins Co of Pitts,PA 19445 Deming,WA 98244 - 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. 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 INSR WVD POLICY NUMBER (MMIDD/Yl'1'Y) (MM/DD/YYYY) LIMITS A X COMMERCIAL GENERAL LIABILITY X X EG13579318 11/23/2021 11/23/2022 EACH OCCURRENCE $1,000,000 CLAIMS-MADE OCCUR PREMISES(ERENTED occu ence) $300,000 _ - MED EXP(Any one person) $25,000 ' PERSONAL 8 ADV INJURY $1,000,000 GE 'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $2,000,000 RO- POLICY X JECT LOC PRODUCTS-COMP/OP AGG $2,000,000 OTHER: - - Pollution $1,000,000 D AUTOMOBILE LIABILITY X X 035902004 , 02/21/2022 11/23/2022 (E°aBcideD SINGLE LIMIT $1,000,000 X ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED AUTOS ONLY AUTOS BODILY INJURY(Per accident) $ X AUTOS ONLY X NON-OWNED PROPERTY DAMAGE AUTOS ONLY (Per accident) $ _ $ A UMBRELLA LIAB _ OCCUR EGU13579377 11/23/2021 11/23/2022 EACH OCCURRENCE $5,000,000 x EXCESS LIAB X CLAIMS-MADE AGGREGATE $5,000,000 DED X RETENTION$O $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY ) STATUTE ER Y/N ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? N/A (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $ If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ B Professional Liab HPL200197 05/11/2021 05/11/2022 1,000,000 C Install Floater SML93026804 11/23/2021 11/23/2022 1,000,000/$5k ded C Lease/Rent Equip SML93026804 02/21/2022 11/23/2022 100,000/$5k ded DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may attached if more space Is required) . General liability includes$1,000,000 WA Stop Gap coverage. The City of Ashland,Oregon and its elected officials,officers and employees are granted additional insured status on any insurance policies required herein but only with respect to Contractor's services to be provided under contract for:Reeder Gulch H ydroelectric Project.Coverage is primary and non-contributory with waiver of subrogation.Should any of the above described policies be cancelled before expiration date thereof,30 days notice will be provided/10 days notice for non-payment of premium. , CERTIFICATE HOLDER CANCELLATION City of Ashland SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 20 East Main Street ACCORDANCE WITH THE POLICY PROVISIONS. Ashland,OR 97520-0000 ' AUTHORIZED REPRESENTATIVE ' • ©1988-2015 ACORD CORPORATION.All rights reserved. ACORD 25(2016/03) 1 of 1 The ACORD name and logo are registered marks of ACORD #S35062691/M35045395 A)(YZP This page has been left blank intentionally. ENDORSEMENT NO. This endorsement, effective 12:01 AM, November 23, 2021 Forms a part of Policy No.: EG 13579318 Issued to: CANYON INDUSTRIES, INC. By: AIG SPECIALTY INSURANCE COMPANY THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. COVERAGES A, B AND E ADDITIONAL INSURED - DESIGNATED PERSON(S) OR ORGANIZATION(S) ENDORSEMENT This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY AND POLLUTION LEGAL LIABILITY COVERAGE FORM Solely as respects Coverages A, B and E, SECTION II - WHO IS AN INSURED is amended to include as an insured the person(s) or organization(s) shown in the Schedule below, but only with respect to bodily injury, property damage, personal and advertising injury, environmental damage or emergency response costs caused in whole or in part, by your acts or omissions or the acts or omissions of those acting on your behalf: A. In the performance of your work; or _ B. In connection with your premises owned by or rented to you. SCHEDULE Name of Additional Insured Person(s) or Organization(s): BLANKET WHERE REQUIRED BY WRITTEN CONTRACT All other terms, conditions, and exclusions shall remain the same. VC4 AUTHORIZED REPRES TATIVE or countersignature (in states where applicable) 103366 (9/11) PAGE 1 OF 1 CI5034 This page has been left blank intentionally. ENDORSEMENT NO. This endorsement, effective 12:01 AM, November 23, 2021 Forms a part of Policy No: EG 13579318 Issued to: CANYON INDUSTRIES, INC. By: AIG SPECIALTY INSURANCE COMPANY THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED VENDORS ENDORSEMENT - PRIMARY AND NON-CONTRIBUTORY This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY AND POLLUTION LEGAL LIABILITY COVERAGE FORM SCHEDULE Name of Person(s) or Organization(s) (Vendor ): BLANKET WHERE REQUIRED BY WRITTEN CONTRACT Your Products: ALL PRODUCTS OF THE NAMED INSURED Solely as respects Coverages A, E-1, E-2 and E-3, if applicable, SECTION II - WHO IS AN INSURED is amended to include as an insured any person(s) or organization(s) (referred to herein as the "vendor") shown in the Schedule above, but only with respect to bodily injury, property damage, environmental damage, or emergency response costs arising out of your products shown in the Schedule above which are distributed or sold in the regular course of the vendor's business, subject to all of the terms and conditions of this Policy and the additional following exclusions, terms and conditions: 1. The insurance afforded the vendor does not apply to: a. Bodily injury, property damage, environmental damage, or emergency response costs for which the vendor is obligated to pay damages by reason of the assumption of liability in a contract or agreement. This exclusion does not apply to liability for damages that the vendor would have in the absence of the contract or agreement; • b. Any express warranty unauthorized by you; c. Any physical or chemical change in your product made intentionally by the vendor; d. Repackaging, except when unpacked solely for the purpose of inspection, demonstration, testing, or the substitution of parts under instructions from the manufacturer, and then repackaged in the original container; 103388 (10/09) PAGE 1 OF 2 C 14401 ENDORSEMENT NO. 12 (Continued) e. Any failure to make such inspections, adjustments, tests or servicing as the vendor has agreed to make or normally undertakes to make in the usual course of business, in connection with the distribution or sale of your product; f. Demonstration, installation, servicing or repair operations, except such operations performed at the vendor's premises in connection with the sale of your product; g. Your product which, after distribution or sale by you, has been labeled or relabeled, or used as a container, part or ingredient of any other thing or substance, by or for the vendor; or h. Bodily injury, property damage, environmental damage or emergency response costs arising out of the sole negligence of the vendor for its own acts or omissions or those'of its employees or anyone else acting on its behalf. However, this exclusion does not apply to: (1) The exceptions contained in Sub-paragraphs d. or f. above; or (2) Such inspections, adjustments, tests or servicing as the vendor has agreed to make or normally undertakes to make in the usual course of business, in connection with the distribution,or sale of your product. 2. This insurance does not apply to any products you have acquired from a vendor, or any ingredient, part or container,entering into, accompanying or containing such'products. 3. Solely with respect to the coverage afforded to the vendor pursuant to, this Endorsement, SECTION IV- CONDITIONS, paragraph 4. Other Insurance is deleted,in its entirety and replaced with the following: 4. Other Insurance This insurance is primary and non-contributory, and our obligations are not affected by any other insurance carried by such vendor whether primary, excess, contingent, or on any other basis. All other terms, conditions and exclusions shall remain the same. 1).1-i AUTHORIZED REPRES TATIVE or countersignature (in states where applicable) 103388 (10/09) PAGE 2.O F 2 C14401 • ENDORSEMENT NO This endorsement, effective 12:01 AM, November 23, 2021 Forms a part of Policy No: EG 13579318 - Issued to: CANYON INDUSTRIES, INC. By: AIG SPECIALTY INSURANCE COMPANY THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. WAIVER OF TRANSFER OF RIGHTS OF RECOVERY 'AGAINST OTHERS TO US ENDORSEMENT This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY AND • POLLUTION LEGAL LIABILITY-COVERAGE FORM It is hereby agreed as follows: SECTION IV - CONDITIONS, Paragraph 7. Transfer of Rights of Recovery Against Others to Us - Applicable to Coverages A, B, C and E is amended by the addition of the following at the end of such subparagraph: , We waive any right,of recovery we may have against the person or organization shown in the'Schedule below because of payments we make under Coverage A, B, C and E 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 below. SCHEDULE Name of Person or Organization: BLANKET WHERE REQUIRED BY WRITTEN CONTRACT All other terms, conditions, and exclusions shall remain the same. AUTHORIZED REPRES TATIVE or countersignature (in states where applicable) 94283 (3/07) PAGE 1 OF 1 C13021 This page has been left blank intentionally. ENDORSEMENT NO. This endorsement, effective 1201 AM, November 23, 2021 Forms a part of Policy No: EG 13579318 , Issued to: CANYON INDUSTRIES, INC. By: AIG SPECIALTY INSURANCE COMPANY THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. COVERAGES A, B, C AND E ADDITIONAL INSURED - MANAGER OR LESSOR OF PREMISES ENDORSEMENT This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY AND POLLUTION LEGAL LIABILITY COVERAGE FORM SCHEDULE 1. Designation of Premises (Part Leased to You): BLANKET WHERE REQUIRED BY WRITTEN CONTRACT 5500 Blue Heron Lane, Deming, WA'98244 2. Name of Manager or Lessor: BLANKET WHERE REQUIRED BY WRITTEN CONTRACT Daniel A. New Solely as respects Coverages A, B, C and E, SECTION II - WHO IS AN INSURED is amended to include as an insured the person or organization shown in the Schedule above but only with respect to liability arising out of the ownership, maintenance or use of that part of the premises leased to you and shown in the Schedule above and subject to the following additional exclusions: This insurance does not apply fig: 1. Any occurrence which takes place after you cease to be a tenant in that premises. 2. Structural alterations, new construction or demolition operations performed by or on behalf of the manager or lessor shown in the Schedule above. ' All other terms, conditions and exclusions shall remain the same. AUTHORIZED REPRESENTATIVE or countersignature (in states where applicable) 95165 (7/07) PAGE 1 OF 1 CI3129 - This page has been left blank intentionally. POLICY NUMBER: 35902004 COMMERCIAL AUTO CA 04 44 03 10 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. WAIVER OF TRANSFER OF RIGHTS OF RECOVERY AGAINST OTHERS TO US (WAIVER OF SUBROGATION) This endorsement modifies insurance provided under the following: • BUSINESS AUTO COVERAGE FORM BUSINESS AUTO PHYSICAL DAMAGE 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 modi- fied by the endorsement. This endorsement changes the policy effective on the inception date of the policy unless another date is indicated below. Named Insured: Canyon Industries Inc Endorsement Effective Date: 2/21/2022— 11/23/2021 SCHEDULE Name(s)Of Person(s) Or Organization(s): Information required to complete this Schedule, if not shown above,will be shown in the Declarations. The Transfer Of Rights Of Recovery Against Oth- ers To Us Condition does not apply to the person(s) or organization(s) shown in the Schedule, but only to the extent that subrogation is waived prior to the "ac- cident" or the "loss" under a contract with that person or organization. CA 04 44 0310 ©Insurance Services Office, Inc., 2009 Page 1 of 1 - 0 This page has been left blank intentionally. 1 DESIGNATED INSURED This endorsement modifies insurance provided under the following: BUSINESS AUTO COVERAGE FORM GARAGE COVERAGE FORM MOTOR CARRIER COVERAGE FORM TRUCKERS COVERAGE FORM i 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" under the Who Is An Insured Provision of the Coverage Form.This endorsement does not alter coverage provided in the Coverage Form. This endorsement changes the policy effective on the inception date of the policy unless another date is indicated below. Endorsement Effective: 2/21/2022—11/23/2022 Countersigned By: Lex Baugh Named Insured:Canyon Industries Inc (Authorized Representative) Policy Number:35902004 SCHEDULE Name of Person(s)or Organization(s): (If no entry appears above,information required to complete this endorsement will be shown in the Declarations as applicable to the endorsement.) Each person or organization shown in the Schedule is an "insured"for Liability Coverage, but only to the extent that person or organization qualifies as an"insured"under the Who Is An Insured Provision contained in Section II of the Coverage Form. CA 2048 02 99 CA 2048 02 99 USI INSURANCE SERVICES CERTIFICATE RETURN MAIL PROCESSING ,,tg PO BOX 629035 EL DORADO HILLS CA 95762-9035 CITY OF ASHLAND 20 E MAIN ST ASHLAND OR 97520-1849