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HomeMy WebLinkAboutInsurance Certificate: Vitus Construction Inc. EBUF!)NN0EE0ZZZZ* DFSUJGJDBUF!PG!MJBCJMJUZ!JOTVSBODF UIJT!DFSUJGJDBUF!JT!JTTVFE!BT!B!NBUUFS!PG!JOGPSNBUJPO!POMZ!BOE!DPOGFST!OP!SJHIUT!VQPO!UIF!DFSUJGJDBUF!IPMEFS/!UIJT DFSUJGJDBUF!EPFT!OPU!BGGJSNBUJWFMZ!PS!OFHBUJWFMZ!BNFOE-!FYUFOE!PS!BMUFS!UIF!DPWFSBHF!BGGPSEFE!CZ!UIF!QPMJDJFT CFMPX/!!UIJT!DFSUJGJDBUF!PG!JOTVSBODF!EPFT!OPU!DPOTUJUVUF!B!DPOUSBDU!CFUXFFO!UIF!JTTVJOH!JOTVSFS)T*-!BVUIPSJ\[FE SFQSFTFOUBUJWF!PS!QSPEVDFS-!BOE!UIF!DFSUJGJDBUF!IPMEFS/ JNQPSUBOU;!!Jg!uif!dfsujgjdbuf!ipmefs!jt!bo!BEEJUJPOBM!JOTVSFE-!uif!qpmjdz)jft*!nvtu!ibwf!BEEJUJPOBM!JOTVSFE!qspwjtjpot!ps!cf!foepstfe/ Jg!TVCSPHBUJPO!JT!XBJWFE-!tvckfdu!up!uif!ufsnt!boe!dpoejujpot!pg!uif!qpmjdz-!dfsubjo!qpmjdjft!nbz!sfrvjsf!bo!foepstfnfou/!!B!tubufnfou!po uijt!dfsujgjdbuf!epft!opu!dpogfs!sjhiut!up!uif!dfsujgjdbuf!ipmefs!jo!mjfv!pg!tvdi!foepstfnfou)t*/ DPOUBDU QSPEVDFS OBNF; GBY QIPOF )B0D-!Op*; )B0D-!Op-!Fyu*; F.NBJM BEESFTT; JOTVSFS)T*!BGGPSEJOH!DPWFSBHFOBJD!$ JOTVSFS!B!; JOTVSFE JOTVSFS!C!; JOTVSFS!D!; JOTVSFS!E!; JOTVSFS!F!; JOTVSFS!G!; DPWFSBHFTDFSUJGJDBUF!OVNCFS;SFWJTJPO!OVNCFS; UIJT!JT!UP!DFSUJGZ!UIBU!UIF!QPMJDJFT!PG!JOTVSBODF!MJTUFE!CFMPX!IBWF!CFFO!JTTVFE!UP!UIF!JOTVSFE!OBNFE!BCPWF!GPS!UIF!QPMJDZ!QFSJPE JOEJDBUFE/!!OPUXJUITUBOEJOH!BOZ!SFRVJSFNFOU-!UFSN!PS!DPOEJUJPO!PG!BOZ!DPOUSBDU!PS!PUIFS!EPDVNFOU!XJUI!SFTQFDU!UP!XIJDI!UIJT DFSUJGJDBUF!NBZ!CF!JTTVFE!PS!NBZ!QFSUBJO-!UIF!JOTVSBODF!BGGPSEFE!CZ!UIF!QPMJDJFT!EFTDSJCFE!IFSFJO!JT!TVCKFDU!UP!BMM!UIF!UFSNT- FYDMVTJPOT!BOE!DPOEJUJPOT!PG!TVDI!QPMJDJFT/!MJNJUT!TIPXO!NBZ!IBWF!CFFO!SFEVDFE!CZ!QBJE!DMBJNT/ BEEMTVCS JOTSQPMJDZ!FGGQPMJDZ!FYQ UZQF!PG!JOTVSBODFMJNJUT QPMJDZ!OVNCFS MUS)NN0EE0ZZZZ*)NN0EE0ZZZZ* JOTEXWE DPNNFSDJBM!HFOFSBM!MJBCJMJUZ FBDI!PDDVSSFODF% EBNBHF!UP!SFOUFE DMBJNT.NBEFPDDVS% QSFNJTFT!)Fb!pddvssfodf* NFE!FYQ!)Boz!pof!qfstpo*% QFSTPOBM!'!BEW!JOKVSZ% HFO(M!BHHSFHBUF!MJNJU!BQQMJFT!QFS;HFOFSBM!BHHSFHBUF% QSP. QPMJDZMPDQSPEVDUT!.!DPNQ0PQ!BHH% KFDU % PUIFS; DPNCJOFE!TJOHMF!MJNJU BVUPNPCJMF!MJBCJMJUZ% )Fb!bddjefou* BOZ!BVUP CPEJMZ!JOKVSZ!)Qfs!qfstpo*% PXOFETDIFEVMFE CPEJMZ!JOKVSZ!)Qfs!bddjefou*% BVUPT!POMZBVUPT OPO.PXOFE IJSFEQSPQFSUZ!EBNBHF % )Qfs!bddjefou* BVUPT!POMZBVUPT!POMZ % VNCSFMMB!MJBC FBDI!PDDVSSFODF% PDDVS FYDFTT!MJBC DMBJNT.NBEFBHHSFHBUF% % EFESFUFOUJPO% QFSPUI. XPSLFST!DPNQFOTBUJPO TUBUVUFFS BOE!FNQMPZFST(!MJBCJMJUZ Z!0!O BOZQ!SPQSJFUPS0QBSUOFS0FYFDVUJWF F/M/!FBDI!BDDJEFOU% O!0!B PGGJDFS0NFNCFS!FYDMVEFE@ )Nboebupsz!jo!OI* F/M/!EJTFBTF!.!FB!FNQMPZFF% Jg!zft-!eftdsjcf!voefs F/M/!EJTFBTF!.!QPMJDZ!MJNJU% EFTDSJQUJPO!PG!PQFSBUJPOT!cfmpx EFTDSJQUJPO!PG!PQFSBUJPOT!0!MPDBUJPOT!0!WFIJDMFT!!)BDPSE!212-!Beejujpobm!Sfnbslt!Tdifevmf-!nbz!cf!buubdife!jg!npsf!tqbdf!jt!sfrvjsfe* DFSUJGJDBUF!IPMEFSDBODFMMBUJPO TIPVME!BOZ!PG!UIF!BCPWF!EFTDSJCFE!QPMJDJFT!CF!DBODFMMFE!CFGPSF UIF!FYQJSBUJPO!EBUF!UIFSFPG-!OPUJDF!XJMM!CF!EFMJWFSFE!JO BDDPSEBODF!XJUI!UIF!QPMJDZ!QSPWJTJPOT/ BVUIPSJ\[FE!SFQSFTFOUBUJWF ª!2:99.3126!BDPSE!DPSQPSBUJPO/!!Bmm!sjhiut!sftfswfe/ BDPSE!36!)3127014*Uif!BDPSE!obnf!boe!mphp!bsf!sfhjtufsfe!nbslt!pg!BDPSE POLICY NUMBER:A0220510004 ADDITIONAL INSURED - SUPPLEMENTAL DECLARATIONS The following persons or organizations are included as Additional Insureds, but only to the extent provided in the listed endorsement: Any person or organization you are required to add as an additional insured under a written contract or written agreement in effect prior to any loss or damage The person or organization indicated above is included as an additional insured under the following endorsement(s): CG 20 371219Additional Insured - Owners, Lessees Or Contractors - Completed Operations Location and Description of Completed Operations: Jobsites and Operations as described in written contracts with the named insured. Any person or organization you are required to add as an additional insured under a written contract or written agreement in effect prior to any loss or damage The person or organization indicated above is included as an additional insured under the following endorsement(s): CG 20 101219Additional Insured - Owners, Lessees Or Contractors - Scheduled Person Or Organization Location of Covered Operations: Jobsites as described in written contracts with the named insured. Job Description: All Operations with written contract with the named insured. IL 70 600815Notice Of Cancellation To Others Number of Days Notice30 CG 89 05 10 14Page 1 of 1 A022051006/15/2023 Middlesex Insurance Company 100001 0000000000 23166 0 Nb97490bd-52be-44e8-85c1-4ab05d96aa2fb97490bd-52be-44e8-85c1-4ab05d96aa2f POLICY NUMBER: COMMERCIAL GENERAL LIABILITY CG 20 37 12 19 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 Information required to complete this Schedule, if not shown above, will be shown in the Declarations. A.SectionII-WhoIsAnInsured isamendedto B.Withrespecttotheinsuranceaffordedtothese includeasanadditionalinsuredtheperson(s)oradditionalinsureds,thefollowingisaddedto organization(s)shownintheSchedule,butonly Section III - Limits Of Insurance: withrespecttoliabilityfor"bodilyinjury"or Ifcoverageprovidedtotheadditionalinsuredis "propertydamage"caused,inwholeorinpart,by requiredbyacontractoragreement,themostwe "yourwork"atthelocationdesignatedand willpayonbehalfoftheadditionalinsuredisthe describedintheScheduleofthisendorsement amount of insurance: performedforthatadditionalinsuredandincluded 1.Required by the contract or agreement; or in the "products-completed operations hazard". 2.Availableundertheapplicablelimitsof However: insurance; 1.Theinsuranceaffordedtosuchadditional whichever is less. insuredonlyappliestotheextentpermittedby law; and Thisendorsementshallnotincreasethe applicable limits of insurance. 2.Ifcoverageprovidedtotheadditionalinsured isrequiredbyacontractoragreement,the insuranceaffordedtosuchadditionalinsured willnotbebroaderthanthatwhichyouare requiredbythecontractoragreementto provide for such additional insured. © Insurance Services Office, Inc., 2018 CG 20 37 12 19Page 1 of 1 A0220510 06/15/2023 Middlesex Insurance Company 100001 0000000000 23166 0 Nb0bd2b3a-ae18-4d96-8e89-7346310239acb0bd2b3a-ae18-4d96-8e89-7346310239ac POLICY NUMBER: COMMERCIAL GENERAL LIABILITY CG 20 10 12 19 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 Information required to complete this Schedule, if not shown above, will be shown in the Declarations. A.SectionII-WhoIsAnInsured isamendedto B.Withrespecttotheinsuranceaffordedtothese includeasanadditionalinsuredtheperson(s)oradditionalinsureds,thefollowingadditional organization(s)shownintheSchedule,butonlyexclusions apply: withrespecttoliabilityfor"bodilyinjury", Thisinsurancedoesnotapplyto"bodilyinjury"or "propertydamage"or"personalandadvertising "property damage" occurring after: injury" caused, in whole or in part, by: 1.Allwork,includingmaterials,partsor 1.Your acts or omissions; or equipmentfurnishedinconnectionwithsuch 2.Theactsoromissionsofthoseactingonyourwork,ontheproject(otherthanservice, behalf;maintenanceorrepairs)tobeperformedbyor onbehalfoftheadditionalinsured(s)atthe intheperformanceofyourongoingoperationsfor locationofthecoveredoperationshasbeen theadditionalinsured(s)atthelocation(s) completed; or designated above. 2.Thatportionof"yourwork"outofwhichthe However: injuryordamageariseshasbeenputtoits 1.Theinsuranceaffordedtosuchadditional intendedusebyanypersonororganization insuredonlyappliestotheextentpermittedby otherthananothercontractoror law; and subcontractorengagedinperforming operationsforaprincipalasapartofthesame 2.Ifcoverageprovidedtotheadditionalinsured project. isrequiredbyacontractoragreement,the insuranceaffordedtosuchadditionalinsured willnotbebroaderthanthatwhichyouare requiredbythecontractoragreementto provide for such additional insured. © Insurance Services Office, Inc., 2018 CG 20 10 12 19Page 1 of 2 A0220510 06/15/2023 Middlesex Insurance Company 100001 0000000000 23166 0 Nd94a57e1-4760-4e39-8901-fd227061736bd94a57e1-4760-4e39-8901-fd227061736b C.Withrespecttotheinsuranceaffordedtothese 2.Availableundertheapplicablelimitsof additionalinsureds,thefollowingisaddedtoinsurance; Section III - Limits Of Insurance: whichever is less. Ifcoverageprovidedtotheadditionalinsuredis Thisendorsementshallnotincreasethe requiredbyacontractoragreement,themostwe applicable limits of insurance. willpayonbehalfoftheadditionalinsuredisthe amount of insurance: 1.Required by the contract or agreement; or © Insurance Services Office, Inc., 2018 Page 2 of 2CG 20 10 12 19 A0220510 06/15/2023 Middlesex Insurance Company POLICY NUMBER:A0220510004 COMMERCIAL GENERAL LIABILITY CG 24 04 12 19 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. WAIVER OF TRANSFER OF RIGHTS OF RECOVERY AGAINST OTHERS TO US (WAIVER OF SUBROGATION) This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART ELECTRONIC DATA LIABILITY COVERAGE PART LIQUOR LIABILITY COVERAGE PART POLLUTION LIABILITY COVERAGE PART DESIGNATED SITES POLLUTION LIABILITY LIMITED COVERAGE PART DESIGNATED SITES PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE PART RAILROAD PROTECTIVE LIABILITY COVERAGE PART UNDERGROUND STORAGE TANK POLICY DESIGNATED TANKS SCHEDULE Name Of Person(s) Or Organization(s): Any person or organization to whom you are required to waive your right to recover by a written contract or agreement executed prior to loss Information required to complete this Schedule, if not shown above, will be shown in the Declarations. ThefollowingisaddedtoParagraph 8.TransferOf RightsOfRecoveryAgainstOthersToUs of Section IV - Conditions: Wewaiveanyrightofrecoveryagainsttheperson(s) ororganization(s)shownintheScheduleabove becauseofpaymentswemakeunderthisCoverage Part.Suchwaiverbyusappliesonlytotheextent thattheinsuredhaswaiveditsrightofrecovery againstsuchperson(s)ororganization(s)priortoloss. Thisendorsementappliesonlytotheperson(s)or organization(s) shown in the Schedule above. © Insurance Services Office, Inc., 2018 CG 24 04 12 19Page 1 of 1 A0220510 06/15/2023 Middlesex Insurance Company 100001 0000000000 23166 0 N68ad2caa-795b-4fcc-9795-275fee80b9a868ad2caa-795b-4fcc-9795-275fee80b9a8 COMMERCIAL GENERAL LIABILITY CG 20 01 12 19 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 LIQUOR LIABILITY COVERAGE PART PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE PART Thefollowingisaddedtothe OtherInsurance(2)Youhaveagreedinwritinginacontractor Conditionandsupersedesanyprovisiontothe agreementthatthisinsurancewouldbe contrary: primaryandwouldnotseekcontribution fromanyotherinsuranceavailabletothe Primary And Noncontributory Insurance additional insured. Thisinsuranceisprimarytoandwillnotseek contributionfromanyotherinsuranceavailable toanadditionalinsuredunderyourpolicy provided that: (1)TheadditionalinsuredisaNamedInsured under such other insurance; and © Insurance Services Office, Inc., 2018 CG 20 01 12 19Page 1 of 1 A0220510 06/15/2023 Middlesex Insurance Company 100001 0000000000 23166 0 N4fe67d05-c6ce-411b-863e-a4ad908b53e54fe67d05-c6ce-411b-863e-a4ad908b53e5 POLICY NUMBER:A0220510001 ADDITIONAL INTEREST SUPPLEMENTAL DECLARATIONS The following additional interests apply to this policy. Any person or organization you are required to add as an additional insured under a written contract or written agreement in effect prior to any loss or damage. PO Box 1097 Gold Hill, OR 97525-1097 CA 76 010615DesignatedInsured-PrimaryandNoncontributory-CoveredAutosLiability Coverage Any person or organization from whom you are required to waive your right to recover under a written contract or agreement in effect prior to any loss or damage. PO Box 1097 Gold Hill, OR 97525-1097 CA 04 441013WaiverOfTransferOfRightsOfRecoveryAgainstOthersToUs(WaiverOf Subrogation) CA 89 04 10 14Page 1 of 1 A0220510 06/15/2023 Middlesex Insurance Company 100001 0000000000 23166 0 N036a9566-3bed-487e-8132-545431bf5741036a9566-3bed-487e-8132-545431bf5741 POLICY NUMBER: COMMERCIAL AUTO CA 76 01 06 15 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. DESIGNATED INSURED - PRIMARY AND NONCONTRIBUTORY - COVERED AUTOS LIABILITY COVERAGE This endorsement modifies insurance provided under the following: BUSINESS AUTO COVERAGE FORM MOTOR CARRIER COVERAGE FORM AUTO DEALERS COVERAGE FORM Withrespecttocoverageprovidedbythisendorsement,theprovisionsoftheCoverageFormapplyunless modified by this endorsement. Thisendorsementidentifiesperson(s)ororganization(s)whoare"insureds"forCoveredAutosLiabilityCoverage under the Who Is An Insured provision of the Coverage Form. Thisendorsementchangesthepolicyeffectiveontheinceptiondateofthepolicyunlessanotherdateis indicated. Named Insured: Endorsement Effective Date: SCHEDULE Name Of Person(s) Or Organization(s): Information required to complete this Schedule, if not shown above, will be shown in the Declarations. A.Eachpersonororganizationshowninthe B.Primary And Noncontributory Insurance Scheduleisan"insured"for CoveredAutos Thisinsuranceisprimarytoandwillnotseek LiabilityCoverage,butonlytotheextentthat contributionfromanyotherautoinsuranceissued personororganizationqualifiesasan"insured" tothepersonororganizationintheschedule underthe WhoIsAnInsured provisioncontained under your policy provided that: in: (1)ThepersonororganizationisaNamedInsured (1)Paragraph A.1.of SectionII-CoveredAutos under such other insurance; and LiabilityCoverage intheBusinessAutoand (2)Priortothe“accident”youhaveagreedin Motor Carrier Coverage Forms; or writinginacontractoragreementthatthis (2)Paragraph D.2.of SectionI-CoveredAutos insurancewouldbeprimaryandwouldnot Coverages oftheAutoDealersCoverage seekcontributionfromanyotherinsurance Form. available to the person or organization. Includes copyrighted material of Insurance Services Office, Inc., CA 76 01 06 15Page 1 of 1 A0220510 with its permission. 06/15/2023 Middlesex Insurance Company 100001 0000000000 23166 0 Nc5565d63-c7b0-4230-b696-db7ec0b5ef83c5565d63-c7b0-4230-b696-db7ec0b5ef83 POLICY NUMBER: COMMERCIAL AUTO CA 04 44 10 13 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. WAIVER OF TRANSFER OF RIGHTS OF RECOVERY AGAINST OTHERS TO US (WAIVER OF SUBROGATION) This endorsement modifies insurance provided under the following: AUTO DEALERS COVERAGE FORM BUSINESS AUTO COVERAGE FORM MOTOR CARRIER COVERAGE FORM Withrespecttocoverageprovidedbythisendorsement,theprovisionsoftheCoverageFormapplyunless modified by the endorsement. Thisendorsementchangesthepolicyeffectiveontheinceptiondateofthepolicyunlessanotherdateis indicated below. Named Insured: Endorsement Effective Date: SCHEDULE Name(s) Of Person(s) Or Organization(s): Information required to complete this Schedule, if not shown above, will be shown in the Declarations. The TransferOfRightsOfRecoveryAgainst OthersToUs conditiondoesnotapplytothe person(s)ororganization(s)shownintheSchedule, butonlytotheextentthatsubrogationiswaived priortothe"accident"orthe"loss"underacontract with that person or organization. © Insurance Services Office, Inc., 2011 CA 04 44 10 13Page 1 of 1 A0220510 06/15/2023 Middlesex Insurance Company 100001 0000000000 23166 0 Nbef6c105-e45d-444d-8a41-6b5b2361617cbef6c105-e45d-444d-8a41-6b5b2361617c