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HomeMy WebLinkAbout1 - Original Submission_ ACORD Form 20210225-09183202/25/2021 WCLA Insurance Agency P O Box 2168 Olympia WA 98507-2168 Joanne Hurley (360) 352-5033 2 (360) 352-1689 joanne@loggers.com Mt. St. Helens Reforestation, Inc. PO Box 971 Chehalis WA 98532 American Forest Cas. Co., RRG 2020 A Loggers BFPD Y AFC040404-20 03/23/2020 03/23/2021 1,000,000 100,000 5,000 1,000,000 2,000,000 2,000,000 A CA9948 AFC040404-20 03/23/2020 03/23/2021 1,000,000 A AFC040404-20 WA Stop Gap 03/23/2020 03/23/2021 1,000,000 1,000,000 1,000,000 A Pesticide AFC040404-20 03/23/2020 03/23/2021 Limit $50,000 Certificate holder is named additional insured with respect to the operation of the named insured. Public Works & Utilities 100 Oyster Bay Ave N Bremerton WA 98312 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. INSURER(S) AFFORDING COVERAGE INSURER F : INSURER E : INSURER D : INSURER C : INSURER B : INSURER A : NAIC # NAME:CONTACT (A/C, No):FAX E-MAILADDRESS: PRODUCER (A/C, No, Ext):PHONE INSURED REVISION NUMBER:CERTIFICATE NUMBER:COVERAGES 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). 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. OTHER: (Per accident) (Ea accident) $ $ N / A SUBR WVD ADDL INSD 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. $ $ $ $PROPERTY DAMAGE BODILY INJURY (Per accident) BODILY INJURY (Per person) COMBINED SINGLE LIMIT AUTOS ONLY AUTOSAUTOS ONLY NON-OWNED SCHEDULEDOWNED ANY AUTO AUTOMOBILE LIABILITY Y / N WORKERS COMPENSATION AND EMPLOYERS' LIABILITY OFFICER/MEMBER EXCLUDED? (Mandatory in NH) DESCRIPTION OF OPERATIONS below If yes, describe under ANY PROPRIETOR/PARTNER/EXECUTIVE $ $ $ E.L. DISEASE - POLICY LIMIT E.L. DISEASE - EA EMPLOYEE E.L. EACH ACCIDENT EROTH-STATUTEPER LIMITS(MM/DD/YYYY)POLICY EXP(MM/DD/YYYY)POLICY EFFPOLICY NUMBERTYPE OF INSURANCELTRINSR DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) EXCESS LIAB UMBRELLA LIAB $EACH OCCURRENCE $AGGREGATE $ OCCUR CLAIMS-MADE DED RETENTION $ $PRODUCTS - COMP/OP AGG $GENERAL AGGREGATE $PERSONAL & ADV INJURY $MED EXP (Any one person) $EACH OCCURRENCE DAMAGE TO RENTED $PREMISES (Ea occurrence) COMMERCIAL GENERAL LIABILITY CLAIMS-MADE OCCUR GEN'L AGGREGATE LIMIT APPLIES PER: POLICY PRO-JECT LOC CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DD/YYYY) CANCELLATION AUTHORIZED REPRESENTATIVE ACORD 25 (2016/03) © 1988-2015 ACORD CORPORATION. All rights reserved. CERTIFICATE HOLDER The ACORD name and logo are registered marks of ACORD HIRED AUTOS ONLY DocuSign Envelope ID: 10EA15A4-B6B1-46E4-A513-17FE37921BC1 INSURED: Mt. St. Helens Reforestation, Inc. COMMERCIAL GENERAL LIABILITY POLICY NUMBER: AFC040404-20 AFGL 2036 (01-10) EFFECTIVE: 03/23/2020 – 03/23/2021 Endorsement #: 70 Effective Date of Endorsement: 03/08/2021 Date Issued: 03/09/2021 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. AFGL 2036 (01-10) Copyright, Insurance Services Office, Inc., 1984 Page 1 of 1  WAIVER OF TRANSFER OF RIGHTS OF RECOVERY AGAINST OTHERS This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART. SCHEDULE Name of Person or Organization: City of Bremerton, Public Works & Utilities Project(s): Planting Trees (lf no entry appears above, information required to complete this endorsement will be shown in the Declarations as applicable to this endorsement.) We waive any right of recovery we may have against the person or organization shown in the Schedule because of payments we make for injury or damage arising out of your ongoing operations done under a cont ract with that person or organization. The waiver applies only to the person or org anization shown in the Schedule. DocuSign Envelope ID: 10EA15A4-B6B1-46E4-A513-17FE37921BC1 COMMERCIAL AUTO INSURED: Mt. St. Helens Reforestation, Inc. POLICY NUMBER: AFC040404-20 EFFECTIVE: 03/23/2020 – 03/23/2021 CA 04 44 03 10 Endorsement #: 71 Effective Date of Endorsement: 03/08/2021 Date Issued: 03/09/2021 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. CA 04 44 03 10 © Insurance Services Office, Inc., 2009 Page 1 of 1  WAIVER OF TRANSFER OF RIGHTS OF RECOVERY AGAINST OTHERS TO US (WAIVER OF SUBROGATION) This endorsement modifies insurance provided under the following: BUSINESS AUTO COVERAGE FORM BUSINESS AUTO PHYSICAL DAMAGE COVERAGE FORM GARAGE COVERAGE FORM MOTOR CARRIER COVERAGE FORM TRUCKERS COVERAGE FORM With respect to coverage provided by this endo rsement, the provisions of the Coverage Form apply unless modi- fied by the endorsement. This endorsement changes the policy effective on the inception date of th e policy unless another date is indicated below. Named Insured: Mt. St. Helens Reforestation, Inc. Endorsement Effective Date: 03/08/2021 SCHEDULE Name(s) Of Person(s) Or Organization(s): City of Bremerton, Public Works & Utilities Information required to complete this Schedule, if not shown above, will be shown in the Declarations. The Transfer Of Rights Of Recovery Against Oth- ers To Us Condition does not apply to the person(s) or organization(s) shown in the Schedule, but only to the extent that subrogation is waived prior to the "ac- cident" or the "loss" under a contract with that person or organization. DocuSign Envelope ID: 10EA15A4-B6B1-46E4-A513-17FE37921BC1 INSURED: Mt. St. Helens Reforestation, Inc. POLICY NUMBER: AFC040404-20 EFFECTIVE: 03/23/2020 – 03/23/2021 COMMERCIAL AUTO CA 20 48 02 99 Endorsement #: 72 Effective Date of Endorsement: 03/08/2021 Date Issued: 03/09/2021 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. CA 20 48 02 99 (REV) Copyright, Insurance Services Office, Inc., 1998 Page 1 of 2  DESIGNATED INSURED This endorsement modifies insurance provided under the following: BUSINESS AUTO COVERAGE FORM GARAGE COVERAGE FORM MOTOR CARRIER COVERAGE FORM TRUCKERS COVERAGE FORM With respect to coverage provided by this endorsement, the provisi ons of the Coverage Form apply unless mod i- fied by this endorsement. This endorsement identifies person(s) or organization(s) who are "insureds" under the Who Is An Insured Prov i- sion of the Coverage Form. This endorsement does not alter coverage provided in the Coverage Form. This endorsement changes the policy effective on the inception date of the policy unless another date is ind icated below. Endorsement Effective: 03/08/2021 Countersigned By: Named Insured: Mt. St. Helens Reforestation, Inc. (Authorized Representative) SCHEDULE Name of Person(s) or Organization(s): City of Bremerton, Public Works & Utilities (If no entry appears above, information required to complete this endorsement will be shown in the Declarations as applicable to the endorsement.) Each person or organization shown in the Schedule is an "insured" for Liability Coverage, but only to the extent that person or organization qualifies as an "insured" under the Who Is An Insured Provision contained in Section II of the Coverage Form. DocuSign Envelope ID: 10EA15A4-B6B1-46E4-A513-17FE37921BC1 Page 2 of 2 Copyright, Insurance Services Office, Inc., 1998 CA 20 48 02 99  PRIMARY AND NONCONTRIBUTORY – OTHER INSURANCE CONDITION The following is added to the Other Insurance Condi- tion and supersedes any provision to the contrary: Primary And Noncontributory Insurance This insurance is primary to and will not seek contribution from any other insurance available to an additional insured shown in the Schedule above under your policy provided that: (1) The additional insured is a Named Insured under such other insurance; and (2) You have agreed in writing in a contract or agreement that this insurance would be primary and would not seek contribution from any other insurance available to the additional insured. DocuSign Envelope ID: 10EA15A4-B6B1-46E4-A513-17FE37921BC1 INSURED: Mt. St. Helens Reforestation, Inc. COMMERCIAL GENERAL LIABILITY POLICY NUMBER: AFC040404-20 CG 20 12 (12-19) REVISED EFFECTIVE: 03/23/2020 – 03/23/2021 Endorsement #: 73 Effective Date of Endorsement: 03/08/2021 Date Issued: 03/09/2021 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. CG 20 12 12 19 © Insurance Services Office, Inc., 2018 Page 1 of 2 ADDITIONAL INSURED – STATE OR GOVERNMENTAL AGENCY OR SUBDIVISION OR POLITICAL SUBDIVISION – PERMITS OR AUTHORIZATIONS This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE State Or Governmental Agency Or Subdivision Or Political Subdivision: City of Bremerton, Public Works & Utilities 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 include as an additional insured any state or governmental agency or subdivision or political subdivision shown in the Schedule, subject to the following provisions: 1. This insurance applies only with respect to operations performed by you or on your behalf for which the state or governmental agency or subdivision or political subdivision has issued a permit or authorization. However: a. The insurance afforded to such additional insured only applies to the extent permi tted by law; and b. If coverage provided to the additional insured is 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. 2. This insurance does not apply to: a. "Bodily injury", "property damage" or "personal and advertising injury" arising out of operations performed for the federal government, state or municipality; or b. "Bodily injury" or "property damage" included within the "products-completed operations hazard". B. With respect to the insurance afforded to these additional insureds, the following is added to Section III – Limits Of Insurance: If coverage provided to the additional insured is required by a contract or agreement, the most we will pay on behalf of the additional insured is the amount of insurance: 1. Required by the contract or agreement; or 2. Available under the applicable limits of insurance; whichever is less. DocuSign Envelope ID: 10EA15A4-B6B1-46E4-A513-17FE37921BC1 Page 2 of 2 © Insurance Services Office, Inc., 2018 CG 20 12 12 19  This endorsement shall not increase the applicable limits of insurance. PRIMARY AND NONCONTRIBUTORY – OTHER INSURANCE CONDITION The following is added to the Other Insurance Condition and supersedes any provision to the contrary: Primary And Noncontributory Insurance This insurance is primary to and will not seek contribution from any other insurance available to an additional insured shown in the Schedule above under your policy provided that: (1) The additional insured is a Named Insured under such other insurance; and (2) You have agreed in writing in a contract or agreement that this insurance would be primary and would not seek contribution from any other insurance available to the additional insured. DocuSign Envelope ID: 10EA15A4-B6B1-46E4-A513-17FE37921BC1