HomeMy WebLinkAboutInsurance Certificate: KLM Engineering Inc •
ACCORD.— DATE,(MM1DbA'YYY)
CERTIFICATE OF LIABILITY INSURANCE
`,.��- '512!202.
•
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 THEC.ERTIFICATEiHOLDER. '
IMPORTANT: If the certificate holderis:an ADDITIONAL INSURED;the policy(les)must have!ADDITIONAL.INSURED provisions;:ot'be,endorsed.,
If SUBROGATION IS WAIVED, subject to the terms and coridltlons Of the policy, certain'�policles=may.require,an endorsement: A statement on
•this:.certificate"does.not confer,•righta to„the certificateholder.in4104.,of,such endorsement(s),.- •:..•. .
'PRODUCER . , . . CONTACT
• •
TrueNorth.Comp:anies, L.C. .. PHONE, RM Home Office FAX
500 1st St SE (A/C,No.'Ext1 319-366-2723 ,. .... (AIC,No)r.8777810-6374 .. .
E•MAIL';.
.Cedar Rapids:IA•52401 tiooRessi certshtruenorthcornpanies.com .
• - -INSURER(S)AFFORDING COVERAGE. NAIC'#
INSURER A:National Fire lhsuranceCompany of Hartford 20478
INSURED KL MEN••• INSURER B:Western National Mutual Insurance Company 1,5377' •
KLM Engineering,.Inc: • INsURERC:Underwriterssat Lloyd's,Loddon(Illinois) 1571I2
1976 WOoddale Drive, Suite 4.• .
S .Patil M,N.55125 ' :'INSURERD:
',INSURER'E:
' INSURER F: I
COVERAGES CERTIFICATE NUMBER7.1443247301 :' , . • 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 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 BEENIREDUCED BY PAID CLAIMS.
MITI
' TYPE OFINSURANCE. ADDL SUBR`�T .• . POLICY.EFF POLICY EXP.
INSD WW1 . POLICY NUMBER.' (MMIDDIYYYY)- (MMIDDIYYY:Y) LIMITS'
B ' X COMMERCIALGENERAL:LIABIUTY CPP 1276940 5/2/2022 51212023' EACH OCCURRENCE $1;000;000
CLAIMS.MADE X' OCCUR •.
DAMAGEES(Ea'oc u ence) $100.,000' ,
•
MED;EXP'(Any one person) $5;.000 •
• PERSONAL&ADV.INJURY $•1,000,000'
GEN'LAGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE. $2,000,000°
X POLICY •X JECT X LOC ,
PRODUCTS-COMPIOP!AGG, $2;DOD,000'
OTHER:
e AUTOMOBILEUABIUTY. GPP 1276056' 5/212022 512/2023 COMBINED•S'INGLE`LIMIT $1,000,000
Ea',accident, _
• X ANY;AUTO . : BODILY INJURY(Per,'peiecri) '$' •
' OWNED' SCHEDULED
X BODILY INJURY.(Peraccident) $.
AUTOS ONLY• AUTOS
x
HIRED x. NON-OWNED PROPERTY DAMAGE $
• AUTOS ONLY AUTOS ONLY (Per accident)
X HPD HPD:LImiVDeductible $50,00071,000
B X UMBRELLA LIAB X OCCUR ,UM 1046724, 5/212022 5./2/2023,. EACH OCCURRENCE _$'4;000,000' ,
EXCESS LIAR CLAIMS-MADE 'AGGREGATE. $
. DED , X: RETENTION$.1 f1 nnn $
A WORKERSCOMPENSATION•, WC 7 12760000' 512/2022 5/212023' X
STATUTE YRH
AND EMPLOYERS'LIABILITY Y i N'.
ANYPROPRIETOR/PARTNERIEXECUTIIIE . E L EACH ACCIDENT. $1,000;000”
OFFICER(MEMBEREXCLUDED? N/A
(Mendetory'In NH) E.C.DISEASE-EA EMPLOYEE $1,000,000'
It yes}describe under. .. •
DESCRIPTION'OF OPERATIONS`below• E.L.DISEASE-POLICYLIMIT• $1,000,000' ' '
B Leased and Rented Equipment CPP 1276942 512/2022 -5/2/2023 ' Llm(tfbeductible 100,00011,000
C ProfesslonalUabllity' ' HPL210641 4112312021, 51212023: Oxurrenoe/Aggregate 2000000/2000000
C Prpfesslcnal Umbrepa HMPL210390 • 11/2312021 5/712023Occurrence/Aggregate . 100000071000000
DESCRIPTION'OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Addillonel Remarks Schedule,they be;attached if;more space Is required)
If Yes is indicated above•,for Additional,Insured,Gan eral;Li ability,form:#WNGL139 06118(ongoing and completed operations):;and Automobile Liability
#WNCA27'06/16'apply,if Yes Is indicated above for Waiver of Subrogation,.General Liability form•#WNGL39 0811:8,Automobile Liability#WNCA27;06116='and
'Workers Compensation#WC0003`13.04/84.apply,Coverageis extended for;work performedrand'required under written:contract•with the above.named insured•,
CERTIFICATE HOLDER CANCELLATION.
SHOULD,ANY OF THE ABOVE'DESCRIBED POLICIES BE CANCELLED BEFORE •
THE EXPIRATION DATE, THEREOF, NOTICE 'WILL BE DELIVERED IN ;
ACCORDANCE WIT,H'THE'POLICY PROVISIONS
City,of;Ashland Dept of Public Works '
20 East Main 51 Wlnbum Way AUTHORIZEDREPRESENTATIVE -
Ashland,.OR'97520 '
. • • ••Oc 1.988-2015 ACORD CORPORATION. All rights:resenied.
ACORD125(2016!03) The ACORD name and logo are;.registered'marks,of ACOR,D.
2••of 2 8908
TrueNorth Companies, L.C.
500 1st St SE
Cedar Rapids, IA 52401
8908 1 MM 0.494 8908
JIii1I"11111IIIIIIuIIIIIIIIIIuIIIiiJIIIIIIuIII illi IIIIIIIuIII
CITY OF ASHLAND DEPT OF PUBLIC WORKS
20 E MAIN 51 WINBURN WAY
ASHLAND, OR 97520
1•of2 8908