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HomeMy WebLinkAboutInsurance Certificate: F.D.Thomas Inc Page 1. of 2 DATE(MM/DD/YYYY) A�f Lf CERTIFICATE OF LIABILITY INSURANCE 05/20/2021 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(les)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 NAME: Willis Towers Watson Certificate Center Willis Towers Watson insurance Services West, Inc. PHONE. FAX FAX 1-88B-467=2378 c/o 26 Century Blvd to/C.No.Ext): (AIC,No): P.O. Box 305191 E-MAIL DRESS:'certificates@willis•.corn. Nashville, TN 372305191' USA INSURER(S)AFFORDING COVERAGE NAIC# INSURER A: ACE American Insurance Company 22667 INSUREDINSURERB: ACE Property 6 Casualty Insurance Company 20699 F.D. Thomas, Inc. 217 Bateman Drive, INSURER C: Tokio Marine Specialty Insurance Company 23850 Central Point, OR 97502 1INSURER D: Berkley Assurance Company 39462 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER:W20994295 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. LTR TYPE OF INSURANCE ADDL SUBR POLICY.EFF POLICY EXP INSD WVD POLICY NUMBER (MM/DD/YYYY) (MM/DD/YYYY) LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 3,000,000 AMAGE CLAIMS-MADE X OCCUR PREM SES(Ea occurrence)REN $ 100 000 A MED EXP(Any one person) $ 10,000 Y BOO G72472421 06/01/2021 06/01/2022 PERSONAL&ADV INJURY $ 3,000,000 GE 'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 3,000,000 POLICY X 28FLOC PRODUCTS-COMP/OP AGG• $ 3,000,000 OTHER: $' AUTOMOBILELIABILITY COMBINED SINGLE LIMIT $ , 5,000,000 (Ea accident) X ANY AUTO BODILY INJURY(Per person) $ A OWNED ^ SCHEDULED ISA 1108874185 06/01/2021 06/01/2022 ,BODILY INJURY(Per accident), $ AUTOS ONLY AUTOS HIRED NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY _ AUTOS ONLY (Per accident) Comp/Coll Ded: $ 1,000.00 B X UMBRELLA UAB X OCCUR EACH OCCURRENCE $ 10,000,000 EXCESS UAB CLAIMS-MADE X00 G28122676 006 06/01/2021 06/01/2022 AGGREGATE $ 10,000,000 DED X RETENTIONS 50,000 $ WORKERS COMPENSATION X STATUTE 0TH AND EMPLOYERS'LIABILITY A ANYPROPRIETOR/PARTNER/EXECUTIVE Y/NE.L.EACH'.ACCIDENT $ 2,000,000 OFFICER/MEMBEREXCLUDED? No N/A WLR C68930522 06/01/2021 06/01/2022 2;000,000 (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $ If yes,describe under 2,000,000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ C Contractors Pollution Liability PPE2275163 06/01/2021 06/01/2022 Per Incident $5,000,000, Aggregate Limit $5,000,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space Is required) PDT Job Number: 70862; PDT Job Name: City of Ashland — Effluent Launder. Clarifier SEE ATTACHED CERTIFICATE HOLDER CANCELLATION SHOULD ANY.OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. City of Ashland AUTHORIZED REPRESENTATIVE 20 E. Main Street `D, `A� Ashland, OR 97520 :4t✓ s ©1988-2016 ACORD CORPORATION. All rights`reserved. ACORD 25(2016/03) The ACORD name and Logo are registered marks•.of ACORD SR ID: 21110950 mai: 2102315 2of7 2545 AGENCY CUSTOMER ID: • LOC#: ACCORD® ADDITIONAL REMARKS SCHEDULE Page 2 of 2 AGENCY NAMED INSURED Willis Towers Watson Insurance Services West, Inc. F.D. Thomas, Inc. _ 217 Bateman Drive, 'POLICY NUMBER Central Point, :OR 97502 See Page 1 "CARRIER NAIC CODE• ' See Page 1 See Page' 1 EFFECTIVE DATE:,See Page 1 ADDITIONAL REMARKS_ • - THIS ADDITIONAL REMARKS FORM IS-A SCHEDULE TO ACORD FORM, FORM NUMBER: 25 FORM TITLE: Certificate of Liability Insurance Coverage for Contractual -Liability is provided under General Liability policy. The-City of Ashland, Oregon, its officers, agents and employees are included as Additional Insureds as respects to General Liability. 'General Liability policy shall be Primary to any other insurance in force; for or which may be purchased by-Additional Insureds. INSURER AFFORDING COVERAGE: Berkley Assurance Company NAIC#: 39462 POLICY NUMBER: PCAB-5013807-0221 REF DATE: 02/14/2021 EXP DATE 02/14/2022 TYPE OF INSURANCE: LIMIT DESCRIPTION: LIMIT AMOUNT: Professional Liability 'Each Claim $5,,000,000 Aggregate Limit $5,000,000 • • • • ACORD1,01 (2008/01) ©2008'ACORD CORPORATION. All rights reserved. The ACORD name and logo are-registered marks of ACORD' SR ID: 2.111095'0 BATCH: 2102315 CERT: W20994295 66 POLICY NUMBER: HDO G72472421 Endorsement Number: COMMERCIAL GENERAL LIABILITY CG 20 10 0413 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 SCHEDULE Name Of Additional Insured Person(s) Or Organization(s) Location(s)Of Covered Operations Any person or organization whom you have agreed to All locations whereyou are performing ongoing include as an additional insured under a written -operations for such,additional insured pursuant to any contract, provided such contract was executed prior to such written contract. the date of loss. 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 insurance afforded to these include as an additional insured,the person(s) or additional insureds, the following additional organization(s) shown in the Schedule, but only exclusions apply: with respect toliability for"bodily injury", "property This insurance does not apply to. "bodily injury" or damage" y or ,personal and advertising injury" "property damage" occurring after: caused, in whole or in part, by: 1. Your acts or omissions; or 1. All work, including. materials, parts or equipment furnished in connection with such 2. The acts or omissions of those acting on your work, on the project (other than service, behalf; maintenance or repairs) to be performed by or in the performance of your ongoing operations for on behalf of the ,additional insured(s) at the the additional insured(s) at the location(s) location of the covered operations has been designated above. completed; or However: 2. That portion of "your work' out of which the injury or damage arises has been, put to its 1. The insurance afforded to such additional intended use by any person or organization insured only applies to the extent permitted by other thananother contractor or subcontractor law; and engaged in performing operations for a 2. If coverage provided to the additional insured is principal as a part of the same project. required by a contract or agreement, the C. With respect to the insurance afforded to these insurance afforded to such additional insured additional, insureds, the following is added to will not be broader than that which you are Section III-Limits Of Insurance: required by the contract or agreement to provide for such additional insured. If coverage provided to the additional insured is required by a contract or agreement, the most we CG 20 10 04 13 ©Insurance Services Office, Inc., 2012 Page 1 of':2 3of7 2545 will pay on behalf of the additional insured is the whichever is less. amount of insurance: This endorsement shall not increase the 1. Required by the contract or agreement; or applicable Limits of Insurance shown in the 2. Available under the applicable Limits of Declarations. Insurance shown in the Declarations; Page 2 of 2 © Insurance Services Office, Inc., 2012 CG 20 10 04 13 1' POLICY NUMBER: HDO-G72472421 Endorsement Number; COMMERCIAL GENERAL LIABILITY CG20370413 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT.CAREFULLY. ADDITIONAL INSURED - OWNERS., LESSEES OR CONTRACTORS - COMPLETED OPERATIONS Thisendorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE PART SCHEDULE Name Of.Additional Insured Person(s) Or Organization(s) Location And Description Of Completed.Operations, Any person or organization whom you have agreed to All locations where you perform work for such additional include as an additional insured under a written insured pursuant to any such,written contract. contract, provided such contract was executed prior to the date of loss. 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 insurance afforded, to these Include as an additionalinsured the person(s) or additional insureds, the following 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 provide for such additional insured. CG 20 37 04 13 ©Insurance.Services Office, Inc.,2012 Page 1 of .1 4 of 7 2545 NON-CONTRIBUTORY ENDORSEMENT FOR ADDITIONAL INSUREDS Named Insured Endorsement Number ASRC Industrial Services, LLC Policy Symbol Policy Number Policy Period Effective Date of Endorsement HDO G72472421 06/01/2021 to 06/01/2022 Issued By(Name of Insurance Company) ACE American Insurance Company Insert the policy number.The remainder of the information is to be completedonly when this endorsement is issued subsequent to the preparation of the policy. THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. COMMERCIAL GENERAL LIABILITY COVERAGE Schedule Organization Additional Insured Endorsement Any additional insured to whom you have agreed to provide such non-contributory insurance,pursuant to and as required under a written contract executed prior to the date of loss. (If no information is filled in,the schedule shall read:"All persons or entities added as additional insureds through an endorsement with the term"Additional Insured"in the title) For organizations that are listed in the Schedule above that are also an Additional Insured under an endorsement attached to this policy, the following is added to Section IV.4.a: If other insurance is available to an insured we cover under any of the endorsements listed or described above (the "Additional Insured") for a loss we cover under this policy, this insurance will apply to such loss on a primary basis and we will not seek contribution from the other insurance available to the Additional Insured. Authorized Agent LD-20287(06/06) Page 1 of 1 NOTICE TO OTHERS ENDORSEMENT-SCHEDULE EMAIL ONLY Named Insured ASRC Industrial Services, LLC Endorsement Number 17 Policy Symbol Policy Number Policy,Period Effective Date of Endorsement H DO G72472421 06/01/2021 To 06/01/2022 Issued By(Name of Insurance Company) .. ;ACE American Insurance Company 'Insert the policy number.The remainder of the information is to be completed only when this endorsement is issued subsequent to the preparation of the policy. THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. A. If we cancel the Policy prior to its expiration date by notice to you or the first Named Insured for any reason other than nonpayment of premium,wewill endeavor,as set out below,to send written notice of cancellation, via such electronic notification as we determine, to the persons or organizations listed in the schedule that you or your representative. provide or have provided to us (the "Schedule"). You or your representative must provide us with the e-mail address of such persons or organizations, and we willutilize such e-mail address that you or your representative provided to us on such Schedule. B. The Schedule must be initially provided to us within 15 days after: i. The beginning of the Policy period, if this endorsement is effective as of such date;or ii. This endorsement has been added to the Policy, if this endorsement is effective after the Policy period commences. C. The Schedule must be in an electronic format that is acceptable to us;and'must be accurate. D. Our delivery ofthe notification as described in Paragraph A. of this endorsement will be based:on the most recent Schedule in our records as of the date the notice of cancellation is mailedor delivered to the first Named Insured. E. We will endeavor to send such notice to the e-mail address corresponding to each person or organization indicated in the Schedule at least 30 days prior to the cancellation date applicable to the Policy. F. The notice referenced in this endorsement is intended only to be a. courtesy notification to the person(s) or organization(s) named in the Schedule in the event of a pending, cancellation of coverage. We. have no legal obligation of any kind to any such person(s) or organization(s). Our failure to provide advance notification of cancellation to the person(s) or organization(s) shown in the Schedule shall impose no obligation or liability of any kind upon us, our agents or representatives, will not extend any Policy cancellation date and will not negate any cancellation of the Policy. G. We are not responsible for verifying any information provided to us in any Schedule, nor are we responsible for any incorrect information that you or your representative provide to us. If you or your representative does not provide us with a Schedule, we have no responsibility for taking any action under this endorsement. In addition, if neither you nor your representative provides us with e-mail address information with respect to a particular person or organization, then we shall have no responsibility for taking action with "regard to such person or entity'under this endorsement. H. We may arrange with your representative to send such notice in the event of any such cancellation. I. You will cooperate with us in providing the Schedule,or in causing your representative to provide the Schedule. J. This endorsement does not apply in the event that you cancel the Policy. ALL-32685(01/11) Page 1 of.2 5 of 7 2545 All other terms and conditions of the Policy remain unchanged. Authorized Representative ALL-32685(01/11) Page 2 of 2 1 NOTICE TO OTHERS ENDORSEMENT-SCHEDULE Named Insured ARCTIC SLOPE REGIONAL CORPORATION Endorsement Number Policy Symbol Policy Number Policy Period Effective Date of Endorsement ISA H08874785 06/01/2021 -06/01/2022 Issued 8y(Name of Insurance Company) ACE American Insurance Company Insert the policy number.The remainder of the information is to be completed only when this endorsement is issued subsequent to the preparation of the policy. THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. A. If we cancel the Policy prior to its expiration date by notice to you or the first Named insured for any reason other than nonpayment of premium,we will endeavor, as set out below,to send written notice of cancellation,via such electronic or other form of notification as we determine, to the persons or organizations listed in the schedule that you or your representative provide or have provided to us (the "Schedule"). You or your representative must provide us with the physical and/or e-mail address,of such persons or organizations, and we will utilize such e-mail addressor physical address that you or your representative provided to us on such Schedule. B. The Schedule must be initially provided to us within 15 days after: i. The beginning of the Policy period, if this endorsement is effective as of such date;or ii. This endorsement has been added to the Policy., if this endorsement is• effective after the Policy period commences. C. The Schedule must be in an electronic format that is acceptable to us;and must be accurate. D. Our delivery of the notification as described in Paragraph A. of this endorsement will be based on the most recent Schedule in our records as of the date the notice of cancellation is mailed or delivered to the first Named Insured. E. We will endeavor to send or deliver such notice to thee-mail address or physical 'address corresponding to each person or organization indicated in the Schedule at least 30 days prior to the cancellation date applicable to the Policy. F. The notice referenced in this endorsement is intended only to be a courtesy notification to the person(s) or organization(s) named in the Schedule, in the event of a pending cancellation of coverage. We: have no legal obligation of any kind to any such person(s) or organization(s). Our failure to provide. advance notifiaation of cancellation to the person(s) or organization(s) shown in the Schedule shall impose no obligation or liability of any kind upon us, our agents or representatives, will not extend any Policy cancellation date and will not negate any cancellation of the Policy. G. We are not responsible for verifying any information provided to us in any Schedule, nor are we responsible for any incorrect information that you or your representative provide to us. If you or your representative does not provide us, with a Schedule,we have no responsibility for taking any action under this endorsement. In addition, if neither you nor your representative provides us with e-mail and physical address information with respect to a particular person or organization, then we shall have no responsibility for taking action with regard to such person or entity under this endorsement. H. We may arrange with your representative to send such notice.in the event of any such cancellation. I. You will cooperate with us in providing the Schedule,or in causing your representative to provide the Schedule. J. This endorsement does not apply in the event that you cancel the Policy. ALL-32687(05/11) Page 1 of 2 6of7 2545 All other terms and conditions of the Policy remain unchanged. Authorized Representative ALL-32687(05/11) Page 2 of 2 Workers' Compensation and Employers' Liability Policy Named Insured Endorsement Number ARCTIC SLOPE REGIONAL CORPORATION 3900 C STREET SUITE 201 Policy Number ANCHORAGE AK 99503 Symbol: WLR Number:068930522. Policy Period Effective Date of Endorsement 06-012021 TO 06-01-2022 06-01-2021 Issued By(Name of Insurance Company) ACE AMERICAN INSURANCE COMPANY Insert the policy number.The remainder of the information;is:to be completed only when this endorsement is issued subsequent to the preparation of the policy. NOTICE TO OTHERS ENDORSEMENT-SCHEDULE-EMAIL ONLY A. If we cancel this.Policy prior to its expiration date by notice to you or the,first Named insured for any reason other than nonpayment of premium,we will endeavor, as set out below;to send written notice of cancellation, via such electronic notification as we determine, to the persons or organizations listed in the schedule that you or your representative provide or have provided to us(the "Schedule"). You or your representative must provide us with the e-mail address of such persons or organizations,and we will utilize such e-mail address that you or your representative provided to us on such Schedule. B. The Schedule must be initially provided to us within 15 days after: i. The beginning,of the Policy period, if this endorsement is effective as of such date;or ii. This endorsement hasbeen added. to the Policy, if this endorsement is effective after the Policy period commences. C. The Schedule must be in an electronic format that is acceptable to us;and:must be accurate. D. Our delivery.ofthe notification as described in Paragraph A. of this endorsement will be based,on the most recent Schedule in our records as of the date the notice of cancellation is mailed or delivered to the,first Named Insured. E. We will endeavor to send such notice to the,e-mail address corresponding to each person or organization indicated in the Schedule at least 30 days prior to the,cancellation date applicable to the Policy. F. The notice referenced in this endorsement is Intended only to be a courtesy notification tothe person(s) or organization(s) named in the Schedule in the event of a pending cancellation of coverage. We have no legal obligationof any kind to any such person(s) or organization(s). Our failure to provide advance notification of cancellation to the person(s) or organization(s) shown in the Schedule shall impose no obligation or liability of any kind upon us, our agents or'representatives, will not extend any Policy cancellation date and will not,negate any cancellation of the Policy. G. We are not responsible for verifying any information provided to us in any Schedule, nor are we responsible for any incorrect information that you or your representative provide torus. If you or your representative does not provide us with a Schedule, we have no responsibility for taking any action under this endorsement. In addition, if neither you. nor your representative provides us with e-mail address information with respect to a particular person or organization, then we shall have no responsibility for taking action with regard to suchperson or entity under this endorsement. H. We may arrange with your representative to,send such notice in the event of any such cancellation. I. You will cooperate with us in providing the Schedule,or in causing your representative to provide the Schedule. J. This endorsement does not apply in the event that you cancel the Policy. All other terms and conditions of this Policy remain unchanged. This Endorsements is not.applicable.in the State of,AZ, FL,,ID, ME,NC,'NJ, NM,TX,:and WI 41111111,4111 Authorized Representative WC 99 03 68(01/11) Pagel 7 of 7 2545 WILLIS TOWERS WATSON 26 CENTURY BLVD. 6TH FL NASHVILLE,TN 37214 2545 2 MB 0.971 IIIIIIIIIIiII"III'IIIII'III'I'IIIIIII'II"I"1IIuiiIIII11"1111 CITY OF ASHLAND 20 E MAIN ST ASHLAND,OR 97520-1814 2545 1 of 7 2545