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HomeMy WebLinkAboutInsurance Certificate: LTM, Inc. A� ® DATE(MM/DD/YYYY) cco CERTIFICATE OF LIABILITY INSURANCE 07/31/2019 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 Marsh USA Inc. NAME:PHONE 333 South 7th Street,Suite 1400 (A/C.No Ext): FAX No): Minneapolis,MN 55402-2400 E-MAIL Attn:MDU.CertRequest@marsh.com;Fax:(212)948-5382 ADDRESS: INSURER(S)AFFORDING COVERAGE NAIC# CN102299309-LTMM-GAWX-19-20 INSURER A:Liberty Mutual Fire Ins Co 23035 INSUREDLTM,Incorporated INSURER B:N/A N/A dba Knife River Materials INSURER C:Liberty Insurance Corporation 42404 PO Box 1145 INSURER D Medford,OR 97501 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: CHI-009317931-03 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 TYPE OF INSURANCE .ADDL SUBR POLICY EFF POLICY EXP LIMITS LTR INSD WVD POLICY NUMBER (MM/DD/YYYY) (MM/DD/YYYY) A X COMMERCIAL GENERAL LIABILITY TB2-641-005097-049 01/01/2019 01/01/2020 EACH OCCURRENCE $ 2,000,000 DAMAGE TO RETED CLAIMS-MADE X OCCUR PREMISES Ea occurrence) $ 1,000,000 MED EXP(Any one person) $ 10,000 PERSONAL&ADV INJURY $ 2,000,000 GEN-'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 4,000,000 _ POLICY X_ JECT LOC PRODUCTS-COMP/OP AGG $ 4,000,000 OTHER: — _ $ A AUTOMOBILE LIABILITY AI2-641-005097-059 01/01/2019 0'1/01/2020 COMBINED SINGLE LIMIT $ 2,000,000 (Ea accident) X ANY AUTO BODILY INJURY(Per person) $ - OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS X HIRED x NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY , AUTOS ONLY (Per accident) UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ C WORKERS COMPENSATION WA7-64D-005097-029(Regulated) 01/01/2019 01/01/2020 X PER OTH- AND EMPLOYERS'LIABILITY STATUTE ER C Y/N WA7-64D-005097-019(AOS) 01/01/2019 01/01/2020 1,000,000 OFFICER/MEMBEREXCLUDED?ECUTIVE N N/A E.L.EACH ACCIDENT $ (Mandatory in NH) "Includes"Stop-Gap"" E.L.DISEASE-EA EMPLOYEE $ 1,000,000 If yes,describe under 1,000,000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS!LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space is required) Re:Asphalt Grinding for the City of Ashland. 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 per the attached CG 2010 and CG 2037 endorsements and does not include professional liability coverage. Blanket Additional Insured for Automobile Liability is included per attached designated Insured Endorsement CA 2048. Primary and Non- Contributory applies for General Liability per CG 20 01 attached. CERTIFICATE HOLDER CANCELLATION City of Ashland SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE 20 East Main Street THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Ashland,OR 97520 ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE of Marsh USA Inc. •Manashi Mukherjee +La�uaea jawr� I ©1588-2016 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD POLICY NUMBER:Al2-641-005097-059 COMMERCIAL AUTO CA 20 48 1013 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. DESIGNATED INSURED FOR COVERED AUTOS LIABILITY COVERAGE This endorsement modifies insurance provided under the following: AUTO DEALERS COVERAGE FORM BUSINESS AUTO COVERAGE FORM MOTOR CARRIER COVERAGE FORM With respect to coverage provided by this endorsement, the provisions of the Coverage Form apply unless modified by the endorsement. This endorsement identifies person(s)or organization(s)who are"insureds"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 Name Of Person(s)Or Organization(s): •I Any person or organization whom you have agreed in writing to add as an additional insured, but only to coverage and minimum limits of insurance required by the written agreement, and in no event to exceed either the scope of coverage or the limits of insurance provided in this policy. This policy will be primary and non-contributory to any like insurance available to the person or organization noted above. Information required to complete this Schedule, if not shown above, will be shown in the Declarations. Each person or organization shown in the Schedule is an "insured"for Covered Autos LiabilityCoverage, but only to the extent that person or organization qualifies as an "insured"under the Who Is An Insured provision contained in Paragraph A.1. of Section II - Covered Autos Liability Coverage in the Business Auto and Motor Carrier Coverage Forms and Paragraph D.2.of Section I - Covered Autos Coverages of the Auto Dealers Coverage Form. CA 20 48 10 13 © Insurance Services Office, Inc., 2011 Page 1 of 1 Policy Number: AI2-641-005097-059 Issued By: Liberty Mutual Fire Insurance 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 LIABILITY COVERAGE 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 certificate holders 90 on file with the Company on file with the Company 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 above. We will send notice to the email or mailing address listed above at least 10 days, or the number of days listed above, if any, before the cancellation becomes effective. In no event does the notice to the third 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 conditions of this policy remain unchanged. LIM 99 01 0511 iV 2011, Liberty Mutual Group of Companies. All rights reserved. Page 1 of 1 Includes copyrighted material of Insurance Services Office, Inc. with its permission. POLICY NUMBER:TB 2-641-005097-049 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 A. Section II — Who Is An Insured is amended to 1. All work, including materials, pats 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 injury, "property maintenance or repairs) to be performed by or damage" or "personal and advertising injury' on behalf of the additional insured(s) at the caused, in whole or in part, by location of the covered operations has been 1. Your acts or omissions; or completed; or 2. The acts or omissions of those acting on your 2. That portion of "your work" out of which the behalf; injury or damage arises has been put to its intended use by any person or organization in the performance of your ongoing operations for other than another contractor or subcontractor the additional insured(s) at the location(s) designated above. engaged in performing operations for a principal as a part of the same project. However: C. With respect to the insurance afforded to these 1. The insurance afforded to such additional additional insureds, the following is added to insured only applies to the extent permitted by Section III—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: not be broader than that which you are required 1. Required by the contract or agreement; or by the contract or agreement to provide for such additional insured. 2. Available under the applicable Limits of B. With respect to the insurance afforded to these Insurance shown in the Declarations; 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 shown in the "property damage" occurring after: Declarations. SCHEDULE CG 2010 0413 rJ Insurance Services Office, Inc., 2012 Page 1 of 2 SCHEDULE(continued) Name Of Additional Insured Person(s) Location(s)Of Covered Operations Or Organization(s): 1.Any person or organization with whom you have All locations as required by a written contract or agreed in writing in a contract or agreement, prior to an agreement entered into prior to an "occurrence" or "occurrence"or"offense",that such person or offense. organization be added as an additional insured on your policy; and 2.Any other person or organization you are required to add as an additional insured under the contract or agreement described in item (1)above Information required to complete this Schedule, if not shown above,will be shown in the Declarations. CG 2010 0413 ©Insurance Services Office, Inc., 2012 Page 2 of 2 POLICY NUMBER:TB2-641-005097-049 COMMERCIAL GENERAL LIABILITY CG 20 37 0413 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 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 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 1. The insurance afforded to such additional Insurance shown in the Declarations; insured only applies to the extent permitted by whichever is less. law; and This endorsement shall not increase the applicable 2. If coverage provided to the additional insured is Limits of Insurance shown in the Declarations. 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 Person(s) Or Organization(s): Location And Description Of Completed Operations Any person or organization with whom you have agreed All locations as required by a written contract or in writing in a contract or agreement, prior to an agreement entered into prior to an "occurrence"or "occurrence"or"offense",that such person or offense. organization be added as an additional insured on your policy; and 2. Any other person or organization you are required to add as an additional insured under the contract or agreement described in item (1) above. Information required to complete this Schedule, if not shown above, will be shown in the Declarations. CG 20 37 0413 ©Insurance Services Office, Inc., 2012 Page 1 of 1 Policy Number TB2-641-005097-049 Issued by LIBERTY MUTUAL FIRE INSURANCE COMPANY 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 LIABILITY COVERAGE PART COMMERCIAL LIABILITY—UMBRELLA COVERAGE FORM Schedule Name of Other Person(s)! Email Address or mailing address: Number Days Notice: Organization(s): Per Schedule of certificate 90 holders on file with the Company • 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 above. We will send notice to the email or mailing address listed above at least 10 days, or the number of days listed above, if any, before the cancellation becomes effective. In no event does the notice to the third 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 conditions of this policy remain unchanged. LIM 99 01 05 11 ©2011 Liberty Mutual Group of Companies.All rights reserved. Page 1 of 1 Includes copyrighted material of Insurance Services Office, Inc.,with its permission. Policy No: TB2-641-005097-049 COMMERCIAL GENERAL LIABILITY CG 20 01 0413 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY, PRIMARY AND NONCONTRIBUTORY - OTHER INSURANCE CONDITION This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE PART The following is added to the Other Insurance (2) You have agreed in writing in a contract or Condition and supersedes any provision to the agreement that this insurance would be contrary primary and would not seek contribution Primary And Noncontributory Insurance from any ether insurance available to the additional insured. This insurance is primary to and will not seek contribution from any other insurance available to an additional insured under your policy provided that: (1) The additional insured is a Named Insured under such other insurance; and CG 20 01 0413 0 Insurance Services Office, Inc., 2012 Page 1 of 1 NOTICE OF CANCELLATION TO THIRD PARTIES 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 below. We will send notice to the email or mailing address listed below at least 10 days, or the number of days listed below, if any, before cancellation becomes effective. In no event does the notice to the third 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. Schedule Name of Other Persons)I Email Address or mailing address: Number Days Notice: Organization(s): Per schedule of certificate Per schedule of certificate 90 holders on file with the holders on file with the company company All other terms and conditions of this policy remain unchanged. Issued by Liberty Insurance Corporation 21814 For attachment to Policy No. WA7-64D-05097-019 Effective Date Premium $ Issued to Centennial Energy Holdings, Inc. WC 99 20 75 ©2016 Liberty Mutual Insurance Page 1 of 1 Ed. 12/01/2016 NOTICE OF CANCELLATION TO THIRD PARTIES 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 below. We will send notice to the email or mailing address listed below at least 10 days, or the number of days listed below, if any, before cancellation becomes effective. In no event does the notice to the third 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. Schedule Name of Other Person(s)I Email Address or mailing address: Number Days Notice: Organization(s): Per schedule of certificate Per schedule of certificate 90 holders on file with the holders on file with the company company All other terms and conditions of this policy remain unchanged. Issued by Liberty Mutual Fire Insurance Company 16586 For attachment to Policy No. WA7-64D005097-029 Effective Date Premium $ Issued to MDU Resources Group, Inc. WC 99 20 75 ©2016 Liberty Mutual Insurance Page 1 of 1 Ed. 12/01/2016