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HomeMy WebLinkAbout3 - Legal Review Submission_ Updated COI (2)INSR ADDLSUBRLTRINSRWVD DATE (MM/DD/YYYY) PRODUCER CONTACTNAME: FAXPHONE(A/C, No):(A/C, No, Ext): E-MAILADDRESS: INSURER A : INSURED INSURER B : INSURER C : INSURER D : INSURER E : INSURER F : POLICY NUMBER POLICY EFF POLICY EXPTYPE OF INSURANCE LIMITS(MM/DD/YYYY)(MM/DD/YYYY) COMMERCIAL GENERAL LIABILITY AUTOMOBILE LIABILITY UMBRELLA LIAB EXCESS LIAB WORKERS COMPENSATION AND EMPLOYERS' LIABILITY DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) AUTHORIZED REPRESENTATIVE INSURER(S) AFFORDING COVERAGE NAIC # Y / N N / A (Mandatory in NH) ANY PROPRIETOR/PARTNER/EXECUTIVEOFFICER/MEMBER EXCLUDED? EACH OCCURRENCE $ DAMAGE TO RENTED $PREMISES (Ea occurrence)CLAIMS-MADE OCCUR MED EXP (Any one person)$ PERSONAL & ADV INJURY $ GENERAL AGGREGATE $GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP/OP AGG $ $ PRO- OTHER: LOCJECT COMBINED SINGLE LIMIT $(Ea accident) BODILY INJURY (Per person)$ANY AUTO OWNED SCHEDULED BODILY INJURY (Per accident)$AUTOS ONLY AUTOS AUTOS ONLYHIRED PROPERTY DAMAGE $AUTOS ONLY (Per accident) $ OCCUR EACH OCCURRENCE $ CLAIMS-MADE AGGREGATE $ DED RETENTION $$ PER OTH- STATUTE ER E.L. EACH ACCIDENT $ E.L. DISEASE - EA EMPLOYEE $ If yes, describe under E.L. DISEASE - POLICY LIMIT $DESCRIPTION OF OPERATIONS below POLICY NON-OWNED SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. 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. 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(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 any rights to the certificate holder in lieu of such endorsement(s). COVERAGES CERTIFICATE NUMBER:REVISION NUMBER: CERTIFICATE HOLDER CANCELLATION © 1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORDACORD 25 (2016/03) ACORDTM CERTIFICATE OF LIABILITY INSURANCE Arch Insurance Company Navigators Insurance Company Sirius International Insurance Corp 8/09/2021 Propel Insurance Tacoma Commercial Insurance 1201 Pacific Ave, Suite 1000 Tacoma, WA 98402 Kim Kleindl 800 499-0933 866 577-1326 Kim.Kleindl@propelinsurance.com Long Painting Company 21414 68th Avenue South Kent, WA 98032 11150 42307 38776 A X X X BI/PD Ded: $25,000 X 71PKG8950817 12/31/2020 12/31/2021 1,000,000 100,000 5,000 1,000,000 2,000,000 2,000,000 A X X X 71PKG8950817 12/31/2020 12/31/2021 1,000,000 B X X 0 SE20EXC556766IV 12/31/2020 12/31/2021 5,000,000 5,000,000 A N 71WCI8916117 USL&H WA Stop Gap 12/31/2020 12/31/2021 X X 1,000,000 1,000,000 1,000,000 C Contractors Pollution Liab CPLS00012382 12/31/2020 12/31/2021 $10,000,000 Limit $25,000 Deductible RE: L210101 - Casad Dam Morning Glory Overflow Coating Replacement. City of Bremerton 345 6th Street, Suite 100 Bremerton, WA 98337 1 of 1 #S4728250/M4424599 LONGPAINClient#: 113165 KMK00 1 of 1 #S4728250/M4424599 DocuSign Envelope ID: 62F92162-7896-4ACC-A195-F360D247E1BB This page has been left blank intentionally. DocuSign Envelope ID: 62F92162-7896-4ACC-A195-F360D247E1BB ADVANCE COPY ADVANCE COPY ADVANCE COPY COMMERCIAL GENERAL LIABILITY CG 20 01 04 13 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. CG 20 01 04 13 © Insurance Services Office, Inc., 2012 Page 1 of 1 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 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 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: 62F92162-7896-4ACC-A195-F360D247E1BB ADVANCE COPY Endorsement Number: Policy Number: 71PKG8950817 Named Insured: LONG PAINTING COMPANY This endorsement is effective on the inception date of this Policy unless otherwise stated herein: Endorsement Effective Date: 12/31/2020 00 CA0115 00 10 13 Page 1 of 1 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - BLANKET This endorsement modifies insurance provided under the following: AUTO DEALERS COVERAGE FORM BUSINESS AUTO COVERAGE FORM MOTOR CARRIER COVERAGE FORM Under Covered Autos Liability Coverage, the Who is An Insured provision is amended to include as an "insured" the person or organization who is required under a written contract to be included as an "insured" under this policy, but only with respect to their legal liability for your acts or omissions or the act or omissions of a person for whom Covered Autos Liability Coverage is afforded under this policy. All other terms and conditions of this policy remain unchanged. DocuSign Envelope ID: 62F92162-7896-4ACC-A195-F360D247E1BB Endorsement Number: This endorsement is effective on the inception date of this policy unless otherwise stated herein. (The information below is required only when this endorsement is issued subsequent to preparation of the policy.) Policy Number: 71PKG8950817 Named Insured: LONG PAINTING COMPANY Endorsement Effective Date: 12/31/2020 00 CA0116 00 04 10 Page 1 of 1 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. PRIMARY AND NON-CONTRIBUTING INSURANCE ENDORSEMENT - DESIGNATED CONTRACT(S) This endorsement modifies insurance provided under the following: BUSINESS AUTO COVERAGE FORM GARAGE COVERAGE FORM SCHEDULE Designated Contract(s): ALL PARTIES WHERE REQUIRED IN A WRITTEN CONTRACT With respect to the contract(s) designated in the Schedule above, it is agreed that the following subparagraph e. is added to SECTION IV - BUSINESS AUTO CONDITIONS, Paragraph B. 5. and SECTION V – GARAGE CONDITIONS, Paragraph B. 5. 5.Other Insurance e.With respect to SECTION II - LIABILITY COVERAGE, where you are specifically required by a written contract designated in the Schedule above to provide insurance that is primary and non-contributory, and the written contract designated in the Schedule above so requiring is executed by you before any “accident”, this insurance will be primary and the other insurance will not contribute with this insurance, but only to the extent required by that written contract. All other terms and conditions of this Policy remain unchanged. DocuSign Envelope ID: 62F92162-7896-4ACC-A195-F360D247E1BB This page has been left blank intentionally. DocuSign Envelope ID: 62F92162-7896-4ACC-A195-F360D247E1BB