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HomeMy WebLinkAboutInsurance Certificate: LTM, Inc. (2) • CITY PECOR i R '''� • Ac • Q® CERTIFICATE OF LIABILITY"INSURANCE DATE(MM/DD/YYYY) 1 , 09/09/2019 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 CdR 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 . Marsh USA Inc. NAME: PHONE i FAX 333 South 7th Street,Suite 1400 - (AIC.No.Esti: (NC,No): Minneapolis,MN 55402-240Q E-MAIL DRILss: • Attn:MDU.CertRequest@marsh.com;Fax:(212)948-5382 INSURER(S)AFFORDING COVERAGE NAIC# CN102299309-LTMM-GAWX-19-20 INSURER A:Uberty Mutual Fire Ins Co 23035 INSURED INSURER B:N/A N/A LTM,Incorporated dba Knife River Materials INSURER c:Liberty Insurance Corporation 42404 PO Box 1145 . Medford,OR 97501 INSURER D: ± INSURER E: . t INSURER F: • COVERAGES CERTIFICATE NUMBER: CHI-009337065-01 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 I ' LTR TYPE OF INSURANCE INS!) WVD POLICY NUMBER (MMIDDIYYYY) (MMIDD/YYYY)• LIMITS • A X COMMERCIAL GENERAL LIABILITY . TB2-641-005097-049 01/01/2019 01/01/2020 , EACH OCCURRENCE $ 2,000,000 D CLAIMS-MADE X OCCUR DAMAGE TO( a occurrence) 1,000,000 - PREMISES(Ea occurrence) $ - MED EXP(Any one person) $ 10,000 t2,000,000 PERSONAL 8 ADV INJURY $ GEN'L AGGREGATE LIMIT APPUES PER: GENERAL AGGREGATE $ 4,000,000 POLICY X JEC LOC PRODUCTS-COMP/OPAGG $ 4,000,000 OTHER: I $ A AUTOMOBILE LIABILITY Al2-641-005097-059 01/01/2019 01/01/2020 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 t AGGREGATE $ DED RETENTION$ • $ C WORKERS COMPENSATION - WA7-64D-005097-029(Regulated) 01/01/2019 . 01/01/2020 X PER 0TH- AND EMPLOYERS'LIABILITYC Y/NSTATUTE ER ANYPROPRIETOR/PARTNER/EXECUTIVE WA7-64D-005097-019(AOS) 01/01/2019 01/01/2020 E.L.EACH ACCIDENT $ 1,000,000 -OFFICER/MEMBEREXCLUDED? n N/A "Includes°Sto Ga 1,000,000 (Mandatory In NH) "Stopp°° • E.L.DISEASE-EA EMPLOYEE $ If yes,describe under 1,000,000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ • l • DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may he attached If more space is required) , Re:KRM Project No.16191129,North Mountain Park Nature Play Area,Project#000646. l 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 20 48. 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 ,.fit in.,&6:! �d,u rc hi cj.. ©1988-2016 ACORD CORPORATION. All rights reserved. ACORD 25(2016103) The ACORD name and logo are registered marks of ACORD • • • POLICY NUMBER:Al2 641-005097-059 F COMMERCIAL AUTO CA'20 481013 • THIS.ENDORSEMENT CHANGES THE POLICY. ,PLEASE READ IT CAREFULLY. • DESIGNATED INSURED FOR • • COVERED:.AUTOS LIABILITY COVERAGE • This endorsement.modifies-insurance provided under the.folioWing: • • 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 organlzation(s)who are•"Igtsureds!'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(,$)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.policyy will be primary and non-contrtributoryto-any like insurance avaliableetathnoted above. • • • • Information regi lred'to complete this'Schediale;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 f • only tosthe 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 1 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 C6Verage Forni. • • ti • CA 2048/013 ©Insurance Services Office,inc„ 2011 Page 1'of 1 } • Policy Number: Al2-641-005097-059 • • Issued By: tiberty-Mutual Fire 'Insurance Co THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. • NOTICE OF CANCELLATION TO THIRD PARTIES This.endorsement niodifles insurance provided'under the following: BUSINESS AUTO COVERAGE PART. MOTOR CARRIER COVERAGE PART GARAGE COVERAGE PART . TRUCKERS COVERAGE PART • EXCESS AUTOMOBILE LIABILITY.IN.DEMNITY COVERAGE!PART SELF-INSURED TRUCKER EXCESS LIABILITY COVERAGii PART COMMERCIAL GENERAL LIABILITY COVERAGE PART EXCESS COMMERCIAL GENERAL LIABILITY COVERAGE ;?ART PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE PART LIQUOR LIABILITY COVERAGE PART • , Schedule Name of Other Person(s)J Email Address or mailing :Number Organization(s): address: Days • . Notice: • Per schedule Of certificate holders Per schedull,e of certificate holders 90 pn 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,poiicy. All other terms and conditions of this policy rerriaih unchanged. • LIM 99 01 0511 ©2011,Liberty Mutual Group of Companies. All rights reserved. Page 1 of 1s Includes copyrighted material.of Insurance Services..Office, Inc. with Its permission.! • ‘-• POLICY NUMBER:T52-641-005097-049 COMMERCIAL GENERAL LIABILITY' • • CG 2010 04 13 THIS ENDORSEMENT CHANGES THE POLICY.. ?LEASE READ IT CAREFULLY. • • ADDITIONAL INSURED - OWNERS; LESSEES OR CONTRACTORS - SCHEDULED PERSON OR ORGANIZATION • .1 This.endorsement modifies insurance provided under the follpwing:. • COMMERCIAL GENERAL LIABILITY COVERAGE PART I • , . A. Section II — Who Is An Insured is amended. to 1. All work, including materials, parts or '• include as an.additional insured the persori(S.). or .equipment famished in connectionwith such. organization(s) shown in the Schedule, but only with ' work on the project •(cther than' service, respect to liability• for ."bodily injury,' "propertY • imaintenance.or repairs) to be performed by pr damage" or "personal and advertising injuty Ian. behalf of the additional insured(s) at the • caused, in whole or in part, by. .1oCatiOn of the covered operations has been • • • 1. Your acts or omissions; or :coMpleted; pr 2. The..acts or omissions of those .acting on 'your 2. !That 'portion of "yOUr work" out.of which the behalf; „injury or damage ariseShas been put to its intended use:.by:any .person or organization • in the performance of your ongoing operations for other than another contractor or sukontractor the .ad-ditionA insured(s) at the location(s) • • • •engaged in performing operdionsfor a designated *above. principal as a pat of the same project. Hotiiiever: C,With respect to the insimane-affordeci to these 1. .The insurance afforded to such additional adOltional •insUredS, the following is added to insured only applies to the extent permitted by Section III—Limits Ofinsurance: law;and If 4:overage provided to the additional insured is . 2. if coverage provided to theadditional 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 • Insurance shown in the DeclAaticins; B. With respect to the insurance afforded to these .1 • addition a insureds, the: following additionalwhichever is leSS. • • • .exclusions-apply: Ths endorsement shall no.V increase the This insurance does not apply to "bodily injUrY or applicable Limits"a Insurance .shown in the "property damage"occurring.after; Declarations. SCHEDULE • CG 40 10 04 13 O.Insurance Services-Office,.inc., 2012 Page 1 of • 1 SCHEDULE(cont!nudc1) Name Of Additional Insured Person(s) Locatior(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 op your policy;.and 2.Any other person or organization you are requited 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,?ill be:shown in the.Declarations. • • • • • 0 •• • • CG'2010 0413 ©.Insurance Services Office,I.hc., 2012 Page 2 of 2 I . ' F • Policy Number TB2-641-005097=049 Issued by LIBERTY MUTUAL FIRE:INSURANCE COMPANY THIS ENDORSEMENT CHANGES THE POLICY. FLEASE 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 Persons)/ Email Address pr mailing address; Number Days Notice: Organization(s): Per Schedule of certificate 90 holderson file with the Company J I , 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 th4.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. 1 • • LIM 99 01 05 11 ©2011.Liberty Mutual.Group of Companies:All rights reserved; Page 1 of 1 Includes copyrighted material of Insurance jervices Office, Inc:,with • its permission, • • Policy No: TB2-641-0,05097-049 COMMERCIAL GENERAL LIABILITY • CG 20 01 04 13 THIS.ENDORSEMENT CHANGES THE POLICY: PLEASE READ IT CAREFULLY. PRIMARY AND NONCONTRIBUTORY - OTHER. INSURANCE CONDITION. This endorsement modifies insurance provided under the • COMMERCIAL GENERAL LIABILITY COVERAGE PART PRODUCTS/COMPLETED OPERATION SLIABILITY COVERAGE PART • • (2) You haveagreed in writing in.a contract or • The follOwing iS added to the Other insurance Condition and supersedes any provision- to thee • agreement th4 this insurance would be contrary primary and would not•seek Contribution froth any Other insuranee Primary And Noncontributory Insurance available to the additional insured. This insurance is primary to.and will not seek - contribution fromany other insurance available to an additional insured under your. policy • praVided tha: (1) The additional:insured is a Named Insured .under.such other insurance;and • • • • • • • • CG.20 01 04 13 ©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 shownin the Schedule below.We will send notice to the email or mailing address listed below at least 10 days, or the number.ofitlays.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 coveragt is intended as a courtesy only: Our failure to provide such*advance notification will not extend the policy cancellation datenor negate cancellation of the policy. Schedule' • Name of Other Person(s)'1 • Email:.Address or mailing address: Number. Days Notice: Organization(s): Per schedule of certificate Per schedule Of certificate • 9Q. . 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 I For attachment to Policy No. WA7-64D ©5097-0191 Effective Date Premium$ Issued to Centennial Energy Holdings, Inc. . 5 • WC 99 20 75 ©2016Liberty Mutual Insurance Page 1 of 1 Ed. 12/0f/2016 • 7 • 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 natenor 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 cthtificate 90 holders on file with the holders on file with the company company • • • All Other terms and conditions of this policy remain unchanged. • i Issued by Liberty Mutual Fire Insurance Company 16586 For attachment to Policy No. WA7-64D-005097-029 Effective Date• Premium$' Issued to MDU Resources Group, Inc. WC:99 26 75 ©2016Liberty Mutual Insurlance Page 1 of'1 Ed. 12/01/2016 • Kariann Olson From: Tara Kiewel Sent: , Monday, September 30, 2019 2:42 PM • To: Kariann Olson Subject: Re: Missing insurance certs for Knife Rivet Materials Attachments: cert_CHI_City of Ashland_9337065_1.pdf Kariann, • Attached is the Insurance Cert for Knife River. Let me know if you need anything else. • Thank you, • Tara • rGcrc(',e,e1 Administrative Analyst Ashland Parks&Recreation Commission 340 S. Pioneer St.,Ashland,OR 97520 • Tel:541-552-2257 Fax 541-488-5314 www.ashlandparksandrec.org This email transmission is official business of the City of Ashland, and it is subJect to Oregon Public Records law for disclosure and retention. If you have received this message in error,please contact me at 541-552-2257. Thank you. • From: Kariann Olson <kari.olson@ashland.or.us> Sent: Monday,September 30,2019 1:33 PM To:Tara Kiewel<tara.kiewel@ashland.or.us> Cc: Kariann Olson<kari.olson@ashland.or.us> Subject: Missing insurance certs for Knife River Materials Just a heads up. . . There does not appear to be copies of insurance certs with the documentation you submitted for a P0. There is a cert for workers'comp but the vendor name on the cert is Mountain View Paving, not Knife River. PO 20200165 Thank you. Kariann Olson Purchasing Representative City of Ashland • 90 N. Mountain Ave. Ashland, Oregon 97520 Tel 541-488-5354 • Fax 541-488-5320 3 TTY 800-735-2900 kari.olson@ashland.or.us Visit the City's web site at: www.ashland.or.us 1