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HomeMy WebLinkAboutInsurance Certificate: LTM,Inc ACO® DATE(MM/DD/YYYY) L....------ CERTIFICATE OF LIABILITY INSURANCE 06/29/2023 • 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. 7 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 NAME:CONTACT Marsh 1 U.S.Operations MARSH USA LLC. 333 South 7th Street,Suite 1400 (A/c No.Est): 866-966-4664 FAX No): 212-946-5382 Minneapolis,MN 55402-2400 E-MAIL Minneauest@marsh.com uest marsh.com ADDRESS: p q INSURER(S)AFFORDING COVERAGE NAIC# CN103060364-LTMM-GAWX-23-24 LTMME INSURER A:Liberty Mutual Fire Ins Co 23035 INSUREDLTM,IncorporatedINSURER B:N/A , ` N/A ' dba Knife River Materials INSURER C: - PO Box 1145 Medford,OR 97501 INSURER D INSURER E: ' INSURER F: ' COVERAGES • CERTIFICATE NUMBER: CHI-010373300-11 ;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 POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSD,WVD POLICY NUMBER (MM/DD/YYYY) (MM/DD/YYYY) LIMITS A X COMMERCIAL GENERAL LIABILITY ' TB2-641-445905-323 01/01/2023 01/01/2024 EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE X OCCUR DAMAGE TO RENTED 1,000,000 PREMISES(Ea occurrence) $ MED EXP(Any one person) $ 10,000 PERSONAL&,ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ _ 2,000,000 POLICY X JEC LOC PRODUCTS-COMP/OP AGG $ 2,000,000 OTHER: • $ A AUTOMOBILE LIABILITY ,AS2641446115033 06/01/2023, 06/01/2024 COMBINED SINGLE LIMIT $ 5,000,000 (Ea accident) X ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS • HIRED NON-OWNED PROPERTY DAMAGE AUTOS ONLY _ AUTOS ONLY (Per accident) $ i , $ • UMBRELLA OCCUR , EACH OCCURRENCE $— EXCESS LIAB CLAIMS-MADE • AGGREGATE $ DED RETENTION$ - $ A WORKERS COMPENSATION WA264D446115013(AOS) 06/01/2023 06/01/2024 X STATUTE ERH. AND EMPLOYERS'LIABILITY ' A ANYPROPRIETOR/PARTNERIEXECUTIVE Y/N WC2641446115063(MN) 06/01/2023 06/01/2024 1,000,000 OFFICER/MEMBEREXCLUDED? n N/A E.L.EACH ACCIDENT $ (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $ 1,000,000 If yes,describe under 1,000,000 DESCRIPTION OF OPERATIONS below • E.L.DISEASE-POLICY LIMIT $ - A General Liab.Excess Buffer TL2641446115043 ' 06/01/2023 06/01/2024 Each Ocb/Pers.&Adv.Injury 4,000,000 GL Agg./Prod:Comp Ops Agg 4,000,000 -, DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space Is required) Re:Asphalt Delivered. , j ,. The City of Ashland and its officers,employees,and agents while acting within the scope of their duties as such is/are included as additional insured under general liability where required by written contract and does not include professional liability coverage. , Blanket Additional Insured for Automobile Liability is included where required by written contract. Primary and Non-Contributory applies for General Liability where required by written contract. , CERTIFICATE HOLDER CANCELLATION City of Ashland SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE 90 N.Mountain Ave. THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Ashland,OR 97520 ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE Q. of Marsh USA LLC • ©1988-2016 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD . • POLICY INIUMBER:AS -641-4,16116,03' . COMMERCIALAUTO: , . CA20 40 1013 • 'THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY: DESIGNATED INSURED FOR COVERED AUTOS LIABILITY'COVERAGE This endorempni mndifieelneurance provided Pnderthe.:19110wing:, AUTO DEALERS COVERAGE FORM BUSINESS AUTO:COVERAGE FORM • MOTORCARRIER:COVERAGE FORM. - With respect to coverage:provided by-this endorsement, the provisions of'the Coverage Fenn 'apply unless. modified by theendersement This endorsement identifies•person(s)or organization(s)WhgAre:"Insurecis"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 . . Nome'Qf'Person(s)Or:Organization* Any person or OrgenizStion where the named ineurecfhpssgreedby written contract to include.such.person or Orgeni2Stion as a. designated insured; . • • Information reOuired:tordoiripletethis•Schednle,lfliot.shown above,will be shown in theDeclarations. • Each persOrtor organitation.shoWn in the.Schedule.is an"insured"for Covered Autos.Lfability Cp.verage,_but only to the extentthat person or organization citialifies ' as an"insured"under the Who Is Art Insured provision • contained in,IPsragrsph. of Section II - Covered • Autos Liability Coverage..in the Business Auto and Motor Carrier Coverage Forms and Paragraph D,:2i of Section I - Covered Autos Coverages of the Auto • Dealers criversge Forrn. • • • • CA 2048 1013 • InsuranceServices Office, Inc.,2011 Page 1 of 1. • Policy Number:AS2-641-446n5=033 • Issued By: Liberty Mutual .Fire Insurande , . THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. NOTICE OF CANCELLATION TO THIRD'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 INDEMNITYCOVERAGE 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 . .LIQ UOR LIABILITY povpRAGE.PARt • Schedule Name of Other Person(s)/ Email Address or mailing Number Organization(s): address:- Days - Notice: Per, schedule of certificate' holders Per schedule 'of Ciartifitate'liolder` 90 on file with the company ,on with the company • A. If vve cancel.this policy for any reason other than nonpayment of premitini;we will notify the persons or organizations shown in the Schedule above We will send notice to the email er mailing address listed above at least 10 days, or the number of days listed above, if :before the cancellation becomes effective. In no event does the notice to the-third;party exceed the.noticeto the first named insured B. This advance notification of a pending cancellation of coverage is intended pee courtesy oniy. Our failure to provide such advance notification will not extend the policy cancellation date nor negate canceliation of the. All other terms and conditions of this policy remain unchanged LIM 99 01 05 11 2011,-Liberty Mutual Group of Companies. All rights reserved. Pagel of.1 Includes copyrighted material of Insurance ServicesOfficer Inc withits permission. • POLICY NUMBER:TB2-641-446,115-023 „COMMERCIAL GENERAL LIABILITY CG 20 10 12 19 THIS ENDORSEMENT CHANdESTHE POLICY. PLEASE-READ IT CAREFULLY. , ADDITIONAL INSURED - OWNERS LESSEES OR CONTRACTORS- SCHEDULED PERSON OR ORGANIZATION This endorsement modifiesinsPrahce provided.under the following:, COMMERCIAL GENERAL LIABILITY COVERAGE PART A. Section II — WhO Is An Insured it_ahlehded th 1. Al! work, including materials, parts 'or • include as an -additional insured the person(s) or equipment furnished in connection with such organization(s)'shown in the Schedule, but only with work, on the project. (other than service, respect to •liability for "bodily inihry", "Properly maintenance or repairs) to be performed by or . . , damage" or "personal and advertising :injury" r on behalf of the additional insured(s) at the caused,in whole orin part, by: location Of the covered operations has been 1. Your acts or omissions;or completed;or 2 The acts or omissions those aCtihg Oh.your 2. That portion of "your work" out of which the oohalf;' injury or damage arises has been put to its intended use by any person iri the Performance Of your ongoing Operations far other:than?another contractor or.or .organization subcontractor the ,additiOnal insured(s) .at 'the. -location(s) engaged in performing operations for a designated above, Principal as apart of the sanieproiect. However: C. With respect tothe insurance afforded to these 1. The insurance, afforded, to such: aciditiOnal additional insureds, the following is added, to insured only applies to .the extent permitted by Section HI—Limits.of Insurance:, law; and If coverage, provided to,the additional insured is. 2. If coverage provided to the additional insured is required by a contract or agreement the most we required by. .a contract or agreement, the will,Pay on behalf of the additional insured is the insurance afforded to such additional insured will amount of insurance; nOtthe be broader than that which you are required 1. Required by the contract or agreagreementent by contor agreement to provide for such or additional insured. 2. Available under the applicable limits of B. With respect to the insOrance afforded to, these insurance; additional insureds, the following additional whichever is less exclusions apply This endorsement shall not increase the This'insurance does not apply to "bodily injury' or applicable limits of insurance. "property darnage'-occurring after: Schedule Name Of Additional inspretl'Oe.ron(s) Location(s)Of Covered Operations Or Organization(i): Any person or organization for whom yoti haye agreed All locations as regUired by a written Contract or Ina written.contract oragreeynent,,prior to an agreement entered into prier to an"occurrence"„ , . ",occurrence"or offense,that such person or Offense. organization be added as an-additionatinsured to your Information required tO‘ccimplete this Schedule,if riot shown above,:will be shown in theDeclarations. CG 20 10 12 19 Insurance Services Office, Inc,2018 Page 1' of 1. POLICY NUMBER:TB2-641-446115-U23COMMERCIAL GENERAL LIABILITY :CG 20 37 12 19 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ,IT CAREFULLY. ADDITIONAL. INSURED.- OWNERS, LESSEES OR CONTRACTORS - CQMPLETED OPERATIONS This endorsement modifies insurance provided tinder the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE PART A. Section It 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, thefollowing is added to organization(s) shown in the Schedule_, but, only Section III—Limits Cif 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 behalfof 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 hazard 1. Required by the contract or agreement;or However: 2.:Available under the applicable limits of insurance; 1, The insurance afforded to such additional whichever is Tess, insured only applies. to the extent permitted by law; and This endorsement shall not increase the applicable 2: If coverage provided to the additional insured is limits of.insurance, 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. Schedule, Name Of Additional Insured Persons) • Or Organization(s): Location And''Description'Of Completed Operations Any person_or organization for whom you have.agreed All locations as required by a written.contract or. in a written contract or.agreenient, prior to an agreement entered into prior toan"occurrence"or "occurrence" or offense,that such person or offense. organization be added as an additional insured to your policy, Information required to complete this Schedule,if not shown above,will be shown in the Declarations. • • CG 20 37 12 19 ©insurance Services'Office; Inc:,2018 Page 1 of 1 • • Policy Number TB2-641-446115-023 • Issued by Liberty Mutual FireInsurance:Co. THIS ENDORSEMENT CHANGES THE POLICY, PLEASE READ.IT CAREFULLY. NOTICE OF CANCELLATION TO THIRD 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 LIABILITYCOVERAGE PART COMMERCIAL LIABILITY- UMBRELLA•COVERAGE" FORM • 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 of this endorsement: We will send notice to the email or mailing address listed above at least 10 days, or the number ofdays listed above, if any, before the cancellatiori becomes effective. In no event•does the notice to thethird 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 • All other terms and conditionsof this policy remain.unchanged. Schedule. • Name of Other Persons)/ Email Address or mailing'address: Number.Days Notice: Organization(s): 'PerSehedule On File WithThe;Conpany'" "Per Sehedute,OnFiie.With The Company" 90 LIM 99 010511 ©2011, Liberty Mutual Group of Companies. All rights reserved. Page 1 of 1 Includes copyrighted material,of Insurance Services Office, Inc.,:with. • its permission.,