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HomeMy WebLinkAboutInsurance Certificate: PCE Pacific Inc PCEPACI-01 MSWAMY ACORD' DATE(MM/DD/YYYY) 4,.......----- CERTIFICATE OF LIABILITY INSURANCE 5/13/2021 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 Hub International Northwest LLC PHONE PO Box 3018 (A/C,No,Ext):(425)4894500 Ira N0,025)485-8489 Bothell,WA 98041 Ai RIEss:now.info@hubinternational.com INSURER(S)AFFORDING COVERAGE NAIC# INSURER A:Alaska National Insurance Company 38733 INSURED INSURERS:Landmark American Insurance Company 33138 PCE Pacific Inc. INSURER C: 22011 26th Ave SE INSURER D: Bothell,WA 98021 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 ADDL SUBR LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER POLICY EFF POLICY EXP (MM/DD/YVYYI (MMIDD/YYYYI LIMITS A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE I Xi OCCUR X X 21EPS31306 5/13/2021 5/13/2022 PREMISES(EaEoccu D nce) $ 100,000 X WY Stop Gap MED EXP(Any one person) $ 5,000 PERSONAL&ADV INJURY _ $ 1,000,000 GE 'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE _ $ 2+000+000 POLICY X JECT LOC PRODUCTS-COMP/OP AGG $ 2,000,000 OTHER: WA STOP GAP $ 1,000,000 A AUTOMOBILE LIABILITY Ea aBINED SINGLE LIMIT $ 1,000,000 X ANY AUTO X X 21EAS31306 5/13/2021 5/13/2022 BODILY INJURY(Per person) $ OWNED SCHEDULED AUTOS ONLY AUTOS BODILY INJURY(Per accident) $ HIRED NON-OWNED PROPERTY DAMAGE AUTOS ONLY _ AUTOS ONLY (Per accident) $ X Comp ded$1000 X ollision ded — $ $1,000 A UMBRELLA LIAB X OCCUR 5,000,000 EACH OCCURRENCE $ X EXCESS LIAB CLAIMS-MADE 21ELU31306 5/13/2021 5/13/2022 AGGREGATE _ $ 5,000,000 DED X RETENTION$ 10,000 $ A WORKERS ND EMPLO ERS'COMPENSATION X PER ERH ANY PROPRIETOR/PARTNER/EXECUTIVE Y/N 21 EWS31306 5/13/2021 5/13/2022 E.L.EACH ACCIDENT $ 1,000,000 OFFICER/MEMBER EXCLUDED? N/A (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 1,000,000 DESCRIPTIONIf yes,describe under 1,000,000 OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ . B Commercial Umbrella LHA251622 5/13/2021 5/13/2022 $5,000,000 xs 5,000,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) Wyoming Stop Gap included under policy#21 EWS31306 Employers Liability limits:,$1,000,000 each accident/$1,000,000 each employee/$1,000,000 policy limit. City of Ashland is an additional insured and insurance is primary and non-contributory per the attached.Waiver of subrogation applies per the attached. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE City of Ashland THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. 20 E Main Ashland,OR 97520 AUTHORIZED REPRESENTATIVE ACORD 25(2016/03) ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD • (�� Alaska National k INSURANCE COMPANY CONTRACTORS' GENERAL LIABILITY ENHANCEMENT ENDORSEMENT THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. • This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART Coverage afforded under this extension of coverage endorsement does not apply to any person or organization covered as an additional insured on any other endorsement now or hereafter attached to this Coverage Part. • SCHEDULE OF COVERAGES ARE SUMMARIZED BELOW 1. Miscellaneous Additional Insureds 14. In Rem Actions 8 additional insured extensions. 1. MISCELLANEOUS ADDITIONAL INSUREDS Primary and Noncontributory Insurance Section II Who Is An Insured is amended to 2. Damage To Premises Rented to You include as an additional Insured any person or Limit increased to$500,000. organization described in Paragraphs 2.a. through 2.h. below whom you are required to add 3. Medical Payments as an additional insured on this policy under a Limits increased to$15,000. written contract or written agreement. However, Reporting period increased to three years from the written contract or written agreement must be: the date of accident. 1. Currently in effect or becoming effective 4. Non-owned Watercraft during the term of this policy;and Increased to 50 feet. 2. Executed prior to the "bodily injury", 5. Supplementary Payments "property damage"or"personal injury and Cost of bail bonds increased to$10,000. advertising injury", but Daily loss of earnings increased to$500. Only the following persons or organizations 6. Newly Formed Or Acquired Organizations are additional insureds under this Coverage extended to the end of the policy period endorsement and coverage provided to such or the next anniversary of this policy's effective additional insureds is limited as provided date. herein: 7. Liberalization Clause a. State or Governmental Agency or Subdivision or Political Subdivi- 8. Unintentional Failure To Disclose Hazards sions 9. Notice of Occurrence Any state or governmental agency or subdivision or political subdivision 10. Broad Knowledge of Occurrence that has issued a permit in Injuryconnection with operations performed 11. Bodily -Extension of Coverage by you or on your behalf and that you are required by any ordinance, law or 12. Expected Or Intended Injury building code to include as an Reasonable force - bodily injury or property additional insured on this coverage damage. part is an additional insured, but only 13. Blanket Waiver of Subrogation with respect to liability for "bodily Waiver of subrogation where required by written injury", "property damage", "personal contract or written agreement. and advertising injury" arising out of such operations. ANIC GL 1187 07 16 Page 1 of 6 Alaska National INSURANCE COMPANY The insurance provided to such state e. Owners or Other Interests From or political subdivision does not apply Whom Land Has Been Leased to any "bodily injury", "property damage"or"personal and advertising An owner or other interest from whom injury" arising out of operations land has been leased by you but only performed for that state or political with respect to liability arising out of subdivision. the ownership, maintenance or use of that specific part of the land leased to b. Controlling Interest you and subject to the following additional exclusions: Any persons or organizations with a controlling interest in you but only This insurance does not apply to: with respect to their liability arising out of: (1) Any "occurrence" which takes place after you cease to lease (1) Their financial control of you,or that land; or (2) Premises they own, maintain or (2) Structural alterations, new con- control while you lease or occupy struction or demolition operations • these premises. performed by or on behalf of such additional insured. This insurance does not apply to structural alterations, new construc- f. Co-owner of Insured Premises tion and demolition operations performed by or for such additional A co-owner of a premises co-owned insured. by you and covered under this insurance but only with respect to the c. Managers or Lessors of Premises co-owners liability as co-owner of such premises. A manager or lessor of premises but only with respect to liability arising out g. Lessor of Equipment of the ownership, maintenance or use of that specific part of the premises Any person or organization from leased to you and subject to the whom you lease equipment. Such following additional exclusions: person or organization is an additional insured only with respect to This insurance does not apply to: their liability for "bodily injury", "property damage" or "personal and (1) Any "occurrence" which takes Advertising injury" caused, in whole place after you cease to be a or in part, by your maintenance, oper- tenant in that premises;or ation or use of equipment leased to you by such person or organization. (2) Structural alterations, new con- A person's or organization's status as struction or demolition operations an additional insured under this performed by or on behalf of endorsement ends when their written such additional insured. contract or written agreement with you for such leased equipment ends. d. Mortgagee,Assignee or Receiver With respect to the insurance A mortgagee, assignee or receiver afforded these additional insureds, but only with respect to their liability the following additional exclusions as mortgagee, assignee, or receiver apply: and arising out of the ownership, maintenance,or use of a premises by This insurance does not apply: you. (1) To any "occurrence" which takes This insurance does not apply to place after the equipment lease structural alterations, new construc- expires;or tion or demolition operations performed by or for such additional insured. ANIC GL 1187 07 16 Page 2 of 6 4k. Alaska National INSURANCE COMPANY (2) To "bodily injury", "property operations hazard" for the damage", or "personal and additional insured. However, advertising injury" arising out of even if coverage within the the sole negligence of such "products-completed operations additional insured. hazard" is required by the written contract, such coverage is h. Owners, Lessees or Contractors available to the additional insured only if the "bodily injury" or (1) Such person or organization is an "property damage"occurs prior to additional insured for "bodily the end of the time period during injury", "property damage" and which you are required by the "personal and advertising injury" written contract to provide such if, and only to the extent that, the coverage or the expiration date of injury or damage is caused by the policy,whichever comes first. negligent acts or omissions of you or your subcontractor in the Any insurance provided to an additional performance of "your work" to insured designated under Paragraphs 2.a. which the written contract through 2.g. above does not apply to "bodily applies. This person or organi- injury" or "property damage" included within zation does not qualify as an the products-completed operations hazard." additional insured with respect to injury or damage caused in whole Primary And Noncontributory Insurance or in part by independent negligent acts or omissions of The following is added to the Other Insurance such person or organization. Condition and supersedes any provision to the (2) However, this insurance does not contrary: apply to "bodily injury", "property This insurance is primary to and will not seek damage" or "personal and contribution from anyother insurance available to advertising injury" arising out of an architect's, engineer's, or an additional insured under your policy provided surveyor's rendering of or failure that: to render any professional services including: (1) The additional insured is a Named Insured under such other i. the preparing, approving, or insurance;and failing to prepare or approve maps, drawings, opinions, (2) You have agreed in writing in a reports, surveys, change contract or agreement that this orders, design or insurance would be primary and • specifications;and would not seek contribution from any other insurance available to the additional insured. ii. supervisory, inspection, or engineering services. Section III -Limits of Insurance, the following is (3) The insurance provided to this added: additional insured, does not cover "bodily injury" or "property With respect to the insurance afforded to the damage" caused by your additional insureds described in Paragraphs a. negligent acts and omissions in through h. above, the most we will pay on behalf the performance of "your work" of such additional insured is the amount of that occurs within the "products- insurance: completed operations hazard", unless the written contract (1) Required by the contract or contains a specific requirement agreement;or that you procure completed operations coverage or coverage (2) Available under the applicable within the "products-completed Limits of Insurance shown in the Declarations; whichever is less. ANIC GL 1187 07 16 Page 3 of 6 Alaska National t. INSURANCE COMPANY This provision shall not increase the applicable 4. NON-OWNED WATERCRAFT Limits of Insurance shown in the Declaration. A. If endorsement CG 21 09, CG 21 10, CG 24 2. Damage To Premises Rented to You 50, or CG 24 51 is attached to the policy, Paragraph A. 2. g. (2) (b) is replaced by the SECTION III — LIMITS OF INSURANCE, following: Paragraph 6. is replaced by the following: (b) A watercraft that you do not 6. Subject to Paragraph 5. above, the own that is: Damage to Premises Rented to You Limit is the most we will pay under Coverage A for damages because of "property damage" to any one premises, while .(i) Less than 50 feet long: rented to you, or in the case of damage and by fire, while rented to you or temporarily occupied by you with permission of the (ii) Not being used to carry owner. persons or property for a charge. If a limit is shown for Damage to Premises Rented to You the most we will pay under B. If Paragraph A. does not apply, Paragraph g. Coverage A for damages because or "property (2) of 2. EXCLUSION under SECTION I — damage" to any one premises is the Limit shown COVERAGES, COVERAGE A — BODILY in the Declarations or $500,000, whichever is INJURY AND PROPERTY DAMAGE greater. LIABILITY is replaced by the following: 3. MEDICAL PAYMENTS (2) A watercraft that you do not own that is: A. Section III—Limits of Insurance, Paragraph 7.is replaced by the following: (a) Less than 50 feet long;and 7. Subject to Paragraph 5. above the (b) Not being used to carry Medical Expense Limit is the most we will persons or property for a pay under Coverage C for all medical charge. expenses because of "bodily injury" sustained by any one person. 5. SUPPLEMENTARY PAYMENTS If a limit is shown for Medical Expense in A. Under Section I-Supplementary Payments the Declarations the most we will pay - Coverage A and B, Paragraph 1.b., the under Coverage C for all medical limit of$250 shown for the cost of bail bonds expenses because of "bodily injury" is replaced by$10,000; sustained by any one person is the Limit shown in the Declarations or $15,000, B. In Paragraph 1.d., the limit of$250 shown for whichever is greater. daily loss of earnings is replaced by$500. B. This provision 5. (Medical Payments) does 6. NEWLY FORMED OR ACQUIRED not apply if Section I - Coverage C Medical ORGANIZATIONS Payments is excluded either by the provisions of the Coverage Part or by Paragraph 3.a.of Section II-Who Is An Insured endorsement. is deleted and replaced by the following: C. Paragraph 1.a.(3)(b)of Section I-Coverage Coverage under this provision is afforded only C - Medical Payments, is replaced by the until the end of the policy period or the next following: anniversary of this policy's effective date after you acquire or form the organization, whichever is (b) The expenses are incurred earlier. and reported to us within three years of the date of the accident;and ANIC GL 1187 07 16 Page 4 of 6 n,a) Alaska National INSURANCE COMPANY 7. LIBERALIZATION CLAUSE 10. BROAD KNOWLEDGE OF OCCURRENCE If we adopt a change in our forms or rules which The following is added to Paragraph 2.of Section would broaden coverage for contractors under IV -Commercial General Liability Conditions - this endorsement without an additional premium Duties in The Event of Occurrence, Offense, charge, your policy will automatically provide the Claim or Suit: additional coverages as of the date the revision is effective in your state. You must give us or our authorized representative notice of an "occurrence", offense, claim, or"suit" 8. UNINTENTIONAL FAILURE TO DISCLOSE only when the "occurrence", offense, claim or HAZARDS "suit'is known to: SECTION IV — COMMERCIAL GENERAL (1) You, if you are an individual; LIABILITY CONDITIONS — Paragraph 6. — Representations is replaced by the following: (2) A partner, if you are a partnership; 6. Representations (3) An executive officer or the By accepting this policy,you agree: employee designated by you to give such notice, if you are a a. The statements in the Declarations are corporation;or accurate and complete; (4) A manager, if you are a limited b. Those statements are based upon liability company. representations you made to us; and 11. EXPANDED BODILY INJURY c. We have issued this policy in reliance Section V - Definitions, the definition of "bodily upon your representations. injury"is changed to read: The unintentional omission of, or "Bodily injury" means bodily injury, sickness or unintentional error in, any information you disease sustained by a person, including death, provided to us which we relied upon in humiliation, shock, mental anguish or mental issuing this policy will not prejudice your injury by that person at any time which results as rights under this insurance. However, this a consequence of the bodily injury, sickness or provision does not affect our right to collect disease. additional premium or to exercise our rights of cancellation or nonrenewal in accordance 12. EXPECTED OR INTENDED INJURY with applicable laws and regulations. Exclusion a. of Section I - Coverage A - Bodily 9. NOTICE OF OCCURRENCE Injury and Property Damage Liability is replaced by the following: The following is added to Paragraph 2.of Section IV- Commercial General Liability Conditions - a. "Bodily injury" or "property damage" Duties In The Event of Occurrence, Offense, expected or intended from the Claim or Suit: standpoint of the insured. This exclusion does not apply to "bodily Your rights under this Coverage Part will not be injury" or"property damage" resulting prejudiced if you fail to give us notice of an from the use of reasonable force to "occurrence", offense, claim or "suit" and that protect persons or property. failure is solely due to your reasonable belief that the "bodily injury" or "property damage" is not covered under this Coverage Part. However, you shall give written notice of this "occurrence", offense, claim or "suit" to us as soon as you are aware that this insurance may apply to such "occurrence",offense, claim or"suit." ANIC GL 1187 07 16 Page 5 of 6 ni? Alaska National INSURANCE COMPANY 13. BLANKET WAIVER OF SUBROGATION However, this waiver applies only when you have agreed in writing to waive such rights of recovery The Transfer Of Rights Of Recovery Against in a contract or agreement, and only if the Others To Us Condition (Section IV - contract or agreement: Commercial General Liability Conditions) is amended by the addition of the following: 1. Is in effect or becomes effective during the term of this policy; and We waive any right of recovery we may have against any person or organization because of 2. Was executed prior to loss. payments we make for injury or damage arising out of: 14. IN REM ACTIONS 1. Your ongoing operations; or Any action in rem against any vessel owned, operated by or for, or chartered by or for you will 2. "Your work" included in the "products- be treated in the same manner as though the completed operations hazard." action were in personam against you. This endorsement changes the policy to which it is attached and, unless otherwise stated, is effective on the date issued at 12:01 A.M. standard time at your mailing address shown in the policy. The information below is required only when this endorsement is issued subsequent to commencement of the policy. Endorsement Effective Policy No. Insured Endorsement No. 26 Countersigned By Includes copyrighted material of Insurance Services Office, Inc.,with its permission ANIC GL 1187 07 16 Page 6 of 6 2? Alaska National t INSURANCE COMPANY DESIGNATED CONSTRUCTION PROJECT(S)GENERAL AGGREGATE LIMIT THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Designated Construction Project(s): All projects. Information required to complete this Schedule, if not shown above,will be shown in the Declarations. A. For all sums which the insured becomes legally 3. Any payments made under Coverage A for obligated to pay as damages caused by damages or under Coverage C for medical "occurrences" under Section I — Coverage A, and expenses shall reduce the Designated for all medical expenses caused by accidents Construction Project General Aggregate Limit under Section I — Coverage C, which can be for that designated construction project. Such attributed only to ongoing operations at a single payments shall not reduce the General designated construction project shown in the Aggregate Limit shown in the Declarations nor Schedule above: shall they reduce any other Designated 1. A separate Designated Construction Project Construction Project General Aggregate Limit General Aggregate Limit applies to each for any other designated construction project designated construction project, and that limit shown in the Schedule above. is equal to the amount of the General 4. The limits shown in the Declarations for Each Aggregate Limit shown in the Declarations. Occurrence, Damage To Premises Rented To 2. The Designated Construction Project General You and Medical Expense continue to apply. Aggregate Limit is the most we will pay for the However, instead of being subject to the sum of all damages under Coverage A, except General Aggregate Limit shown in the damages because of "bodily injury" or Declarations, such limits will be subject to the "property damage" included in the "products- applicable Designated Construction Project completed operations hazard", and for medical General Aggregate Limit. expenses under Coverage C regardless of the number of: a. Insureds; b. Claims made or"suits"brought; or c. Persons or organizations making claims or bringing"suits". CG 25 03 05 09 Page 1 of 2 �0 Alaska National k INSURANCE COMPANY BUSINESS AUTO COVERAGE ENHANCEMENT ENDORSEMENT THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. This endorsement modifies insurance provided under the following: BUSINESS AUTO COVERAGE FORM Various provisions in this endorsement restrict SECTION IV — Business Auto Conditions, coverage. Read the entire policy carefully to Paragraph A. 5. — Transfer of Rights of Recovery determine rights, duties, and what is and is not Against Others To Us is amended to include: covered. 5. Transfer of Rights of Recovery Against Throughout this policy, the words "you" and "your" Others to Us refer to the Named Insured shown in the Declarations. The words "we", "us", and "our" refer to This condition does not apply to any the company providing this insurance. person(s) or organization(s)to the extent that subrogation against that person or Other words and phrases that appear in quotation organization is waived prior to the "accident" marks have special meaning. Refer to SECTION V— or the"loss"under a contract with that person DEFINITIONS in the Business Auto Coverage Form. or organization. The coverages provided by this endorsement apply SECTION II — COVERED AUTO LIABILITY per "accident" and, unless otherwise specified, are COVERAGE, Paragraph A.2.a. (2)—Supplementary subject to all of the terms, conditions, exclusions and Payments is replaced by the following: deductible provisions of the policy, to which it is attached. (2) Up to $10,000 for cost of bail bonds (including bonds for related traffic law SECTION II — COVERED AUTO LIABILITY violations) required because of an COVERAGE, Paragraph A.1. Who Is An Insured is "accident"we cover. We do not have amended to include: to furnish these bonds. d. Any "employee" of yours while operating SECTION II — COVERED AUTO LIABILITY an "auto" hired or rented under a COVERAGE, Paragraph A.2.a. (4)—Supplementary contract or agreement in an "employee's" Payments is replaced by the following: name, with your permission, while performing duties related to the conduct (4) All reasonable expenses incurred by of your business. the"insured" at our request, including actual loss of earnings up to $500 a e. Any person or organization for whom you day because of time off from work. have agreed in writing to provide insurance such as is afforded by this Coverage Form, but only with respect to liability arising out of the ownership, maintenance or use of"autos"covered by this policy. If such person or organization has other insurance then this insurance is primary to and we will not seek contribution from the other insurance. ANIC CA 1150 10 13 Page 1 of 4 • yc,2/ Alaska National INSURANCE COMPANY C. "Loss" caused by falling objects or SECTION II — COVERED AUTO LIABILITY missiles. COVERAGE, Paragraph A.2.c.—Voluntary Property Damage is added as follows: However, you have the option of having glass breakage caused by a covered "auto's" c. Voluntary Property Damage collision or overturn considered a"loss"under Collision Coverage. At your written request, we may make a voluntary payment for Property Damage Glass Repair—Waiver of Deductible caused by an "insured", but without liability to a third party, up to$25,000.We No deductible applies to glass breakage, if will not make a Voluntary Property the glass is repaired rather than replaced. Damage payment to anyone who is an "insured"under this policy. SECTION III — PHYSICAL DAMAGE COVERAGE, Paragraph A.4.a. — Transportation Expenses is SECTION III — PHYSICAL DAMAGE COVERAGE, replaced by the following: Paragraph A.2.—Towing is replaced by the following: a. Transportation Expenses Towing We will pay up to $200 per day to a We will pay up to $500 for towing and labor maximum of $1,500 for temporary costs incurred each time a covered "auto" transportation expense incurred by you that is a: because of the total theft of a covered "auto"that is a: a. Private passenger; (1) Private passenger; b. Truck; (2) Truck; c. Pick-up truck; (3) Pick-up truck; d. Panel ;or e. Van (4) Panel; or (5) Van type vehicle under 20,000 lbs. of Gross Vehicle Weight is disabled. However, the labor must be performed at place of type vehicle under 20,000 lbs. of Gross disablement. Vehicle Weight. We will pay only for those covered "autos"for which you carry SECTION III — PHYSICAL DAMAGE COVERAGE, either Comprehensive or Specified Paragraph A.3. — Glass Breakage — Hitting a Bird Causes of Loss Coverage. We will pay for temporary transportation expenses or Animal —Falling Objects or Missiles is replaced by the following: incurred during the period beginning 48 hours after the theft and ending, regardless of the policy's expiration, Glass Breakage—Hitting a Bird or Animal when the covered "auto" is returned to —Falling Objects or Missiles use or we pay for its"loss". If you carry Comprehensive Coverage for the damaged covered "auto", we will pay the following under Comprehensive Coverage: a. Glass Breakage; b. "Loss" caused by hitting a bird or animal; and ANIC CA 1150 10 13 Page 2 of 4 7 Alaska National INSURANCE COMPANY (2) Specified Causes of Loss only if the SECTION III — PHYSICAL DAMAGE COVERAGE, Declarations indicate that Specified Paragraph A.4.b. — Loss of Use Expenses is Causes of Loss Coverage is provided replaced by the following: for the"auto"withdrawn from service; or b. Loss of Use Expenses—Hired, Rented, (3) Collision only if the Declarations or Borrowed Automobiles indicate that Collision Coverage is provided for the "auto" withdrawn We will pay expenses for which an from service. "insured" becomes legally responsible to pay for loss of use of a vehicle hired, SECTION III — PHYSICAL DAMAGE COVERAGE, rented or borrowed without a driver under Paragraph A.4.d. — Airbag Coverage is added as a written rental contract or agreement. follows: We will pay for loss of use expenses, if caused by: d. Airbag Coverage (1) Other than Collision, only if the We will pay for the cost to repair, replace, Declarations indicate that or reset an airbag that inflates for any Comprehensive Coverage is provided reason other than as a result of a for the vehicle withdrawn from collision, if the Declarations indicate that service. the covered "auto" has Comprehensive Coverage or Specified Causes of Loss (2) Specified Causes of Loss only if the Coverage. Declarations indicate that Specified Causes of Loss Coverage is provided SECTION III — PHYSICAL DAMAGE COVERAGE, for the vehicle withdrawn from Paragraph A.4.e. — Rental Reimbursement service. Coverage is added as follows: (3) Collision only if the Declarations e. Rental Reimbursement Coverage indicate that Collision Coverage is provided for the vehicle withdrawn We will pay up to $75 per day for rental from service. reimbursement expenses incurred by you for the rental of an "auto" because of However, the most we will pay for any "loss"to a covered"auto"that is a: expenses for loss of use is$200 per day,to a maximum of$1,500. (1) Private Passenger; SECTION III — PHYSICAL DAMAGE COVERAGE, (2) Truck; Paragraph A.4.c.—Non-Transportation Loss of Use Expenses is added as follows: (3) Pick-up truck; c. Non-Transportation Loss of Use (4) Panel; or Expenses (5) Van We will pay up to $2,000 for non- transportation expenseincurred by you, type vehicle under 20,000 lbs. of Gross because of "loss" to a covered "auto", if Vehicle Weight. Payment applies in caused by: addition to the otherwise applicable amount of each coverage you have on a (1) Other than Collision, only if the covered "auto". No deductibles apply to Declarations indicate that this coverage. Comprehensive Coverage is provided for the"auto"withdrawn from service; ANIC CA 1150 10 13 Page 3 of 4 �0 Alaska National k INSURANCE COMPANY (1) We will pay only for those expenses SECTION IV — BUSINESS AUTO CONDITIONS — incurred during the policy period Paragraph B.5.b. — Other Insurance is replaced by beginning 24 hours after the "loss" the following: and ending, regardless of the policy's expiration, with the lesser of the b. For Hired Auto Physical Damage following number of days: Coverage, the following are deemed to be covered"autos"you own: (a) The number of days reasonably required to repair or replace the (1) Any covered "auto" you lease, hire, covered"auto". rent,or borrow; and (b) 30 days. (2) Any covered "auto"" hired or rented by your "employee" under a contract (2) This coverage does not apply while in that individual "employee's" name, there are spare or reserve "autos" with your permission, while available to you for your operations. ' performing duties related to the conduct of your business. (3) The Rental Reimbursement Coverage described above does not However, any"auto"that is leased, hired, apply to a covered "auto" that is rented or borrowed with a driver is not a described or designated as a covered covered"auto". "auto" on Rental Reimbursement Coverage Form CA 99 23. SECTION V — DEFINITIONS — Paragraph C. — "Bodily injury"is replaced by the following: SECTION IV — BUSINESS AUTO CONDITIONS — Paragraph B.2. —Concealment, Misrepresentation Or C. "Bodily injury" means bodily injury, sickness or Fraud is amended by adding Unintentional Failure disease sustained by a person including death or to Disclose Hazards at the end of Paragraph B.2. as mental anguish resulting from any of these. follows: Mental anguish means any type of mental or emotional illness or disease Unintentional Failure to Disclose Hazards If you unintentionally fail to disclose any hazards existing at the inception date of your policy, we will not deny coverage under this Coverage Form because of such failure. However, this provision does not affect our right to collect additional premium or exercise our right of cancellation or non-renewal. This endorsement changes the policy to which it is attached and, unless otherwise stated, is effective on the date issued at 12:01 A.M. standard time at your mailing address shown in the policy. The information below is required only when this endorsement is issued subsequent to commencement of the policy. Endorsement Effective Policy No. Insured Endorsement No. 5 Countersigned By ©Insurance Services Office, Inc., 2009 ANIC CA 1150 10 13 Page 4 of 4 �0 Alaska National • k INSURANCE COMPANY UTAH WAIVER OF SUBROGATION ENDORSEMENT This endorsement applies only to the insurance a written contract that requires you to obtain this provided by the policy because Utah is shown in Item agreement from us.) 3.A.of the Information Page. This agreement shall not operate directly or indirectly We have the right to recover our payments from to benefit anyone not named in the Schedule. Our anyone liable for an injury covered by this policy. We waiver of rights does not release your employees' will not enforce our right against the person or rights against third parties and does not release our organization named in the Schedule. (This agreement authority as trustee of claims against third parties. applies only to the extent that you perform work under SCHEDULE Any person or organization for whom the Insured has agreed by written contract to furnish this waiver. This endorsement changes the policy to which it is attached and, unless otherwise stated, is effective on the date issued at 12:01 A.M. standard time at your mailing address shown in the policy. The information below is required only when this endorsement is issued subsequent to commencement of the policy. Endorsement Effective Policy No. Insured Endorsement No. 8 Countersigned By WC 43 03 05(07 00) ys) Alaska National INSURANCE COMPANY ALASKA BLANKET WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT We have the right to recover our payments from Additional premium charge for this endorsement shall anyone liable for an injury covered by this policy. We be 1.85% of the total standard premium for this policy, will not enforce our right against any person or subject to a$250 minimum annual charge per policy. organization. This agreement applies only to the extent that you perform work under a written contract that requires you to obtain this agreement from us. This endorsement changes the policy to which it is attached and, unless otherwise stated, is effective on the date issued at 12:01 A.M. standard time at your mailing address shown in the policy. The information below is required only when this endorsement is issued subsequent to commencement of the policy. Endorsement Effective Policy No. Insured Endorsement No. 14 Countersigned By WC 99 03 13(01 12) Alaska National 4. INSURANCE COMPANY WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT We have the right to recover our payments from a written contract that requires you to obtain this anyone liable for an injury covered by this policy. We agreement from us.) will not enforce our right against the person or organization named in the Schedule. (This agreement This agreement shall not operate directly or indirectly applies only to the extent that you perform work under to benefit any one not named in the Schedule. SCHEDULE Any person or organization for whom the Insured has agreed by written contract to furnish this • waiver. This endorsement changes the policy to which it is attached and, unless otherwise stated, is effective on the date issued at 12:01 A.M. standard time at your mailing address shown in the policy. The information below is required only when this endorsement is issued subsequent to commencement of the policy. Endorsement Effective Policy No. Insured Endorsement No. 5 Countersigned By WC 00 03 13(04 84) PCE PACIFIC INC Page 1 of 2 STATE OF WASHINGTON Department of Labor& Industries Certificate of Workers' Compensation Coverage May 12, 2021 WA UBI No. 602 546 491 L&I Account ID 107,437-00 Legal Business Name PCE PACIFIC INC Doing Business As PCE PACIFIC INC Workers'Comp Premium Status: Account is current. Estimated Workers Reported Quarter 1 of Year 2021 "76 to 100 (See Description Below) Workers" Account Representative Employer Services Help Line, (360) 902-4817 Licensed Contractor? No What does "Estimated Workers Reported" mean? Estimated workers reported represents the number of full time position requiring at least 480 hours of work per calendar quarter. A single 480 hour position may be filled by one person, or several part time workers. Industrial Insurance Information Employers report and pay premiums each quarter based on hours of employee work already performed, and are liable for premiums found later to be due. Industrial insurance accounts have no policy periods, cancellation dates, limitations of coverage or waiver of subrogation (See RCW 51.12.050 and 51.16.190). https://secure.lni.wa.gov/verify/Details/liabilityCertificate.aspx?UBI=602546491&LIC=&... 5/12/2021 PCE PACIFIC INC Page 2 of 2 https://secure.lni.wa.gov/verify/Details/liabilityCertificate.aspx?UBI=602546491&LIC=&... 5/12/2021 ttaag4 State of Wyoming �oaKFoR F o frr= Department of Workforce Services t� 5221 Yellowstone Rd SFRv+SEs a8y _ Cheyenne, WY 82002 Mark Gordon 307.777.6763-Fax:307.777.5298 Robin Sessions Cooley, J.D. Governor http://www.wyomingworkforce.org Director Elizabeth Gagen,J.D. Deputy Director Recipient: Employer: PCE PACIFIC, INC. P C E PACIFIC INC Attn:JOELLEN THOMPSON 22011 26TH AVE SE 22011 26TH AVENUE SE BOTHELL,WA BOTHELL, WA 98021 98021 WORKERS'COMPENSATION CERTIFICATE OF GOOD STANDING Mail Date: 1/28/2021 EXPIRATION DATE: 1/28/2022 Job Reference: On file This is to certify that the above named employer is in compliance with the Wyoming Workers'Compensation Act. The account is in good standing as of the above date. Wyoming Workers'Compensation monthly/quarterly payroll reports shall be submitted and payments made on or before the last day of the month following the month for which the earnings are computed and paid. Prime contractors may verify good standing of a sub-contractor's business by contacting the Division by telephone, after the initial certificate has been issued. In private work, a contractor is liable for the payment of Workers'Compensation premiums for the employees of any subcontractor, if the subcontractor primarily liable has not paid the premiums as provided in the Act, pursuant to Wyoming Statute 27-14-206. Contractors should request a Certificate of Good Standing from the subcontractor before making final settlement of the contract. If you have any further questions or concerns, please contact our office at 307-777-6763. Sincerely, Office Support Specialist Division of Workers'Compensation