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HomeMy WebLinkAboutInsurance Certificate: F.D. Thomas, Inc. Page 1 of 2 AC�m DATE(MMIDDIYYYY) �. CERTIFICATE OF LIABILITY INSURANCE 02/12/2021 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 CERTIFICATEHOLDER. IMPORTANT: If the certificate,holder Is an ADDITIONAL INSURED,the pollcy(les)must have ADDITIONAL INSURED provisionsor be endorsed. If SUBROGATION IS WAIVED,subject to the terms andconditions 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 CONTAOT Willie Towers 'Watson Certificate Center. NAME: Willie Towers Watson Insurance Services west, Inc. PHONE 1-877-945-7378 FA 1-888-467-2378 c/o 26 Century Blvd IA/C.No.Ext1: {AlC,No): P.O. Box 305191 ADDRESS: certificatesewillie.com Nashville, TN 372305191 USA 'INSURER(S)AFFORDING COVERAGE NAIC# INSURER Al ACE American Ineurance Company 22667 INSUREDINSURERS: ACE Property & Casualty Insurance Company 20699' F.D. Thomas, Inc. Company-TokiMerino S ecialt Insurance Co an 23850 o 217 Bateman Drive, INSURER C: P Y Y Central Point, OR 97502 INSURER D: Berkley Assurance Company 39462 INSURER E: . I INSURER F: COVERAGES CERTIFICATE NUMBER:W20081365 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. IN A11DTS —POLLICY EFF POLICY EXP TR TYPE OF INSURANCE INSD WVD POLICY NUMBER (MMIDD/YYYY) (MMIDD/YYYY) LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 3,000,000 DAMAGE TORENTED CLAIMS-MADE X OCCUR PREMISES(Ea occurrence) $ 100,000 A MED EXP(Any one person) $ 10,000 Y RDO G71080080 001 06/01/2020 '06/01/2021 PERSONAL&ADV INJURY $. 3,000,000 GEN'L AGGREGATE LIMIT APPLIES�` PER: GENERAL AGGREGATE $ 3,000,000 POLICY I " 1 JECT I I LOC PRODUCTS-COMP/OP'AGO $' 3,000,000 OTHER: $ AUTOMOBILE LIABILITY :COMBINED SINGLE LIMIT $ 5,000,000 _ (Ea accident) X ANY AUTO BODILY INJURY(Per person) $ A. OWNED SCHEDULED ISA x08872429 06/01/2020 06/01/2021 BODILY INJURY(Peraccident) ,$ AUTOS ONLY AUTOS HIRED NON-OWNED PROPERTY DAMAGE _ AUTOS ONLY _ AUTOS ONLY (Per accident) $ Comp/Coll Ded: $ 1,000.00 B X UMBRELLALIAB X OCCUR EACH OCCURRENCE , $ 10,000,000 EXCESSLIAB CLAIMS-MADE XOO G28122676 005 06/01/2020 06/01/2021 AGGREGATE $ 10,000,000 DED X RETENTIONS 50,000 $ WORKERS COMPENSATION X 8TA UTE RH AND EMPLOYERS'LIABILITY 2,000 000 A ANYPROPRIET'ORIPARTNER/E?ECUTIVE Y� NIA WLR C48135298 06/01/2020,06/01/2021 E.L.EACH ACCIDENT $ OFFICE ory to NEREXCLUDED. I J2,000 '000 (Mandatory In NH) ' EL.DISEASE-EA EMPLOYEE $ II yes,describe under 2,000,000 DESCRIPTION OF OPERATIONS below E.L.DISEASE•POLICY LIMIT $ C Contractors Pollution Liability PPE2136227 06/01/2020 06/01/2021 Per Incident $5,000,000 Aggregate Limit $5,000,000 DESCRIPTION OF OPERATIONS/LOCATIONS!VEHICLES(ACORD 101,Additional Remarks Schedule,may he 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 POUCIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL 'BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. City of Ashland AUTHORIZED REPRESENTATIVE j� --- 20 E. Main Street c,, 7 Ashland, OR 97520 O 1988.2016 ACORD CORPORATION. All rights'reserved. ACORD 25(2016/03) The-ACORD name and logoare registered marks of ACORD BR. o: 20715036 811,1:oE: 1986098 2 of 7 1020 AGENCY CUSTOMER ID: ----•"'"1" . LOC#: AR ADDITIONAL REMARKS SCHEDULE Page 2 of 2 AGENCY NAMED INSURED Willis Towers Watson Insurance Services West, Inc. F.D. Thomas, Inc. 217 Batamnn 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 EFF 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 ACORD 101 (2008/01) ©2008 ACORD CORPORATION. All rights.reserved. The ACORD name and logo-are registered marks of ACORD SR ID: 20715036 BATCH: 1986098 CERT: W20081365 66 POLICY NUMBER; HDO G71080080 001 Endorsement Number: COMMERCIAL GENERAL LIABILITY CG 20 10 04 13 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 Organizations) Location(s) Of Covered Operations Any person or organization whom you have agreed to All locations where you 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" "personal personal and advertising Injury" "property damage"occurring after: caused, in whole or in part, by: 1, All work, including materials, parts or 1. Your acts or omissions; 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 1. The insurance afforded to such additional injury or damage arises has been' put to Its intended use by any person or organization insured only applies to the extent permitted by other than another 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 0413 ©Insurance Services,Office,.Inc., 2012 Page 1 of 2 3 of 7 1020 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 0413 1 POLICY NUMBER: HDO G71080080 001 Endorsement Number: COMMERCIAL GENERAL LIABILITY CG 20 370413 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - OWNERS LESSEES OR CONTRACTORS COMPLETED OPERATIONS This endorsement 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 additional insured 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 additionalinsured and included in the "products-completed operations 1. Required,by the contractor 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 affordedto 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 1020 NON-CONTRIBUTORY ENDORSEMENT FOR ADDITIONAL INSUREDS Named Insured Endorsement Number ARCTIC SLOPE REGIONAL CORPORATION: Policy Symbol Nolicy Number Policy Period Effective Date of Endorsement HDO G71080080 001 06/01/2020 to 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: 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 ofloss. (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 A9ent LD-20287(06/06) Page 1 of 1 NOTICE TO OTHERS ENDORSEMENT SCHEDULE — EMAIL ONLY Named Insured ARCTIC SLOPE REGIONAL CORPORATION Endorsement Number 1.7 Policy Symbol Policy Number Policy Period Effective Date of Endorsement H DO G71080080 001 06/01/2020 TO 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 Isissued;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`wrltten 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 beginningof 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 such notice to the a-mailaddress 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 endorsementis 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 ono responsibility for taking any action under this endorsement. In addition, if neither you nor your representative provides us with a-mall 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 1020 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, H08872429 06/0.1/2020-06/0.1/2021 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. THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. A. If we cancel the Policy prior to its expiration date by notice toyou or the first Namedinsured for any reasomother 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 address or 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 endorsementhas 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 the e-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 provideadvance notification of cancellation to.the person(s) or organization(s) shown in the Schedule shallimpose 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 youor your representative-does not provide us with a Schedule,we have noresponsibility 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 toa'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 6 of 7 1020 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:C48135298 Policy Period Effective Date of Endorsement 06-01-2020 TO 06-01-2021 06-01-2020 Issued'By(Name of Insurance Company) ACE AMERICAN INSURANCE COMPANY Insert the policy number.The remainder of the information isrto 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 wewill 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 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 such notice to the e-mail address corresponding to each person or organization indicated in the Schedule at least 30 days prior to the,cancellatlon 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 haveno 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 email 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 other terms and conditionsof this Policy remain unchanged. This Endorsements is not applicable in the State of AZ, FL, ID, ME, NC, NJ, NM,TX,and WI Authorized Representative WC 99 03 68(01/11) Page 1 7 of 7 1020