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HomeMy WebLinkAboutCertificate of Liability 04/01/2022Client#:574333 BRISTBAYI O ACORDTM CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) 4/05/2021 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). PRODUCER CONTACT NAME: Jamie Esquivel Marsh&McLennan Agency LLC r,"NN at),907-276-5617 FAX No):1031 W 4th Avenue DRss, jamie.esquivel@marshmc.comSuite400 INSURER(S)AFFORDING COVERAGE NAIC#Anchorage,AK 99501 INSURERA:Evanston Insurance Company 35378 INSURED INSURER B:Navigators Specialty Insurance Company 36056PetroCard, Inc. American Zurich Insurance CompanyINSURERC:p y 40142730SCentralAvenue INSURER D:Zurich American Insurance Company 16535Kent,WA 98032-0000 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: (1)21-22 GAEW 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 ADDLSUBR POLICY EFF POLICY EXPLTRTYPEOFINSURANCEINSRWVDPOLICYNUMBERMM/DD/YYYYLIMM/DD/YYYYL LIMITS A X COMMERCIAL GENERAL LIABILITY MKLV5ENV102958 04/01/2021 04/01/2022 EACH 1,000,000 _ ECLAIMS-MADE X OCCUR PREMISES(Ea oaauence) $300,000 MED EXP(Any one person) $10,000 PERSONAL&ADV INJURY $1,000,000 _ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $2,000,000 POLICY X JECT LOC PRODUCTS-COMP/OP AGG $2,000,000 OTHER: D AUTOMOBILE LIABILITY BAP927545020 04/01/2021 04/01/2022 COMBINED SINGLE LIMIT X ANY AUTO BODILYIINJURY(Per person) $ 1,000,000 OWNED SCHEDULEDAUTOSONLYAUTOS BODILY INJURY(Per accident) $ HIRED NON-OWNED PROPERTY DAMAGEAUTOSONLYAUTOSONLYPeraccident) B UMBRELLA LIAB X OCCUR SF21 EXC725167IC 04/01/2021 04/01/2022 EACH OCCURRENCE 5,000,000 X EXCESS LIAB CLAIMS-MADE AGGREGATE 5,000,000 DED I RETENTION$ C WORKERS COMPENSATION WC588844816 04/01/2021 04/01/2022 X PER OTH- AND EMPLOYERS'LIABILITY Y/N STATUTE ER OFFICERR/MEMBER EXCLUDED?ECUTIVE N N/A E.L.EACH ACCIDENT $1,000,000 Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $1,000,000Ifyes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $1,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space is required) Re: Evidence of Insurance.Subject to said policy limits,terms, and exclusions.Where required by written contract, Certificate Holder is an Additional Insured on the General Liability and Auto Liability policies, subject to the terms, conditions and limitations of said policies and the additional insured endorsement. Where required by written contract,Waiver of Subrogation in favor of Certificate Holder applies to referenced policies subject to the terms, conditions and limitations of said policies and the Waiver of Subrogation endorsement. CERTIFICATE HOLDER CANCELLATION City of Bremerton SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED INFinancialServicesACCORDANCEWITHTHEPOLICYPROVISIONS. 345 Sixth Street Suite 600 AUTHORIZED REPRESENTATIVE Bremerton,WA 98337-1873M4Lti 1988-2015 ACORD CORPORATION.All rights reserved. ACORD 25(2016/03) 1 of 1 The ACORD name and logo are registered marks of ACORD S8174375/M8143112 WAZAW ACo!?©, ADDITIONAL REMARKS SCHEDULE 2Page of 2 AGENCY NAMED INSURED Marsh & McLennan Agency LLC PetroCard, Inc. CARRIER NAIC CODE EFFECTIVE DATE: ADDITIONAL REMARKS THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, FORM NUMBER: 25 FORM TITLE: Certificate of Liability Insurance This is evidence of insurance procured and developed under the Alaska Surplus Lines Law,AS 21.34. It is not covered by the Alaska Insurance Guaranty Association Act,AS 21.80. ACORD 101 (2008/01) 2008 ACORD CORPORATION.All rights reserved. The ACORD name and logo are registered marks of ACORD