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HomeMy WebLinkAboutCity of Bremerton_Certificate of Liability Insurance 2021-2022 PCHS1 of 18 (FJS00) City of Bremerton Fire Department, 911 Park Ave. Bremerton, WA 98337 2 of 18 (FJS00) THIS PAGE INTENTIONALLY LEFT BLANK 3 of 18 (FJS00) CERTIFICATE HOLDER © 1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25 (2010/05) AUTHORIZED REPRESENTATIVE CANCELLATION DATE (MM/DD/YYYY)CERTIFICATE OF LIABILITY INSURANCE LOCJECTPRO-POLICY GEN'L AGGREGATE LIMIT APPLIES PER: OCCURCLAIMS-MADE COMMERCIAL GENERAL LIABILITY GENERAL LIABILITY PREMISES (Ea occurrence)$DAMAGE TO RENTED EACH OCCURRENCE $ MED EXP (Any one person)$ PERSONAL & ADV INJURY $ GENERAL AGGREGATE $ PRODUCTS - COMP/OP AGG $ $RETENTIONDED CLAIMS-MADE OCCUR $ AGGREGATE $ EACH OCCURRENCE $UMBRELLA LIAB EXCESS LIAB DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required) INSRLTR TYPE OF INSURANCE POLICY NUMBER POLICY EFF(MM/DD/YYYY)POLICY EXP(MM/DD/YYYY)LIMITS WC STATU-TORY LIMITS OTH-ER E.L. EACH ACCIDENT E.L. DISEASE - EA EMPLOYEE E.L. DISEASE - POLICY LIMIT $ $ $ ANY PROPRIETOR/PARTNER/EXECUTIVE If yes, describe underDESCRIPTION OF OPERATIONS below (Mandatory in NH)OFFICER/MEMBER EXCLUDED? WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y / N AUTOMOBILE LIABILITY ANY AUTO ALL OWNED SCHEDULED HIRED AUTOS NON-OWNEDAUTOSAUTOS AUTOS COMBINED SINGLE LIMIT BODILY INJURY (Per person) BODILY INJURY (Per accident) PROPERTY DAMAGE $ $ $ $ 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 THISCERTIFICATE 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 WVD SUBR N / A $ $ (Ea accident) (Per accident) 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 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). The ACORD name and logo are registered marks of ACORD COVERAGES CERTIFICATE NUMBER:REVISION NUMBER: INSURED PHONE(A/C, No, Ext): PRODUCER ADDRESS:E-MAIL FAX(A/C, No): CONTACTNAME: NAIC # INSURER A : INSURER B : INSURER C : INSURER D : INSURER E : INSURER F : INSURER(S) AFFORDING COVERAGE SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORETHE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. 03/26/2021 Parker, Smith & Feek, Inc. 2233 112th Avenue NE Bellevue, WA 98004 425-709-3600 425-709-7460 ProSelect Insurance Company Peninsula Community Health Services PO Box 960 Bremerton, WA 98337 Ohio Security Insurance Company A X 1,000,000 8 X 8 8 004WA000001349 04/01/2021 04/01/2022 300,000 5,000 1,000,000 5,000,000 5,000,000 B 1,000,000 8 X BAS2157216533 04/01/2020 04/01/2021 A 2,000,000 8 8 2,000,000 8 -0- 004WA000001349 04/01/2021 04/01/2022 A 804/01/2021 04/01/2022 WA Stop Gap 1,000,000 004WA000001349 ** WA State Stop Gap 1,000,000 1,000,000 A Professional Liability Healthcare Professional - Claims Made 004WA000001349 04/01/2021 04/01/2022 $1M Each Medical Incident$5M Aggregate4/1/2005 Retrodate Holder is included as Additional Insured with Primary and Noncontributory wording and a Waiver of Subrogation on the General Liability per the attached endorsements. Included as Additional Insured on the Auto coverage per the attached endorsement. City of Bremerton is an additional insured on the general liability and automobile policies per the attached endorsements/forms... (See Attached Description) City of Bremerton Fire Department, 911 Park Ave. Bremerton, WA 98337 4 of 18 (FJS00) THIS PAGE INTENTIONALLY LEFT BLANK 5 of 18 (FJS00) DESCRIPTIONS (Continued from Page ) 1 . Waiver of subrogation applies on the general liability policy per the attached endorsement/form. 6 of 18 (FJS00) THIS PAGE INTENTIONALLY LEFT BLANK 7 of 18 (FJS00) 8 of 18 (FJS00) 9 of 18 (FJS00) 10 of 18 (FJS00) 11 of 18 (FJS00) 12 of 18 (FJS00) 13 of 18 (FJS00) 14 of 18 (FJS00) THIS PAGE INTENTIONALLY LEFT BLANK 15 of 18 (FJS00) COVERYS ProSelect Insurance Company ADDITIONAL INSURED - DESIGNATED PERSON OR ORGANIZATION Attached to and forming part of Policy Number: First Named Insured: Policy Period: 004WA000001349 Peninsula Community Health Services 04/01/2020 to 04/01/2021 At 12:01 AM Standard Time at the address of the First Named Insured as stated herein. THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. This endorsement modifies insurance provided underthe following: Commercial General Liability Coverage Part SCHEDULE Name of Additional Insured Person(s) or Organization(s): US Bank N A City of Bremerton Kitsap Pride Network Mason County Public Health Bremerton Foodline Section ll. Definition of Insured is amended to include as an additional INSURED the person(s) or organization(s) shown in the Schedule above, but only with respect to liability for INJURY caused, in whole or in part, by a NAMED INSURED'S acts or omissions or the acts or omissions of those acting on a NAMED INSURED'S behalf: 1. In the performance of a NAMED INSURED'S ongoing operations; or 2, In connection with a NAMED INSURED'S premises owned by or rented to a NAMED INSURED. However: 1, The insurance afforded to such additional INSURED only applies to the extent permitted by law; and 2. 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 a NAMED INSURED is required by the contract or agreement to provide for such additional INSURED, With respect to the insurance afforded to the additional INSUREDS shown in the Schedule above, 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 Limit of Liability shown in the DECLARATIONS; whichever is less. Activity No: 452814 CGL 017 07/14 r2 Date Produced: 04/01/20 11:27 Includes copyrighted material of Insurance Services Office, Inc., with its permission Page 1 16 of 18 (FJS00) COVERYS ProSelect Insurance Company Nothing in this endorsement shall vary, alter, waive or extend any of the terms and conditions of the POLICY, other than as expressly stated above. Activity No: 452814 Gregg L, Hanson Enn B. Bagley President & CEO Assistant Secretary CGL 017 07/14 r2 Date Produced: 04/01/20 11:27 Page 2 Includes copyrighted material of Insurance Services Office, Inc., with its permission 17 of 18 (FJS00) ProSelect Insurance Company Activity No: MAN 002 07/14 r2 Date Produced: 12/30/2020 Page 1 MANUSCRIPT ENDORSEMENT – ADDITIONAL INSURED – PRIMARY NON CONTRIBUTORY WITH WAIVER OF SUBROGATION Attached to and forming part of Policy Number: First Named Insured: Policy Period: Effective Date of Change 004WA000001349 Peninsula Community Health Services 05/01/2020 to 05/01/2021 At 12:01 AM Standard Time at the address of the First Named Insured as stated herein. 12/31/2020 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. This endorsement modifies insurance provided under the following: Commercial General Liability Coverage Part SCHEDULE Name and Address of Person(s) or Organization(s): Party ID: Retroactive Date: Activities: City of Bremerton, its officers, officials, employees, agents and volunteers With respect to those security activities rendered on behalf of the Insured as described in a contract with the Salvation Army Securty Guard Funding Agreement Subject to all other terms and conditions of the POLICY, and with respect to the Interest of the Person(s) or Organization(s) listed in the Schedule above, it is agreed and understood that: A. Section II. Definition of Insured is amended to include as an additional INSURED the Person(s) or Organization(s) shown in the Schedule above, subject to the RETROACTIVE DATE shown in the Schedule above, but only with respect to the activities indicated above. However: 1. The insurance afforded to such additional INSURED only applies to the extent permitted by law; and 2. 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 a NAMED INSURED is required by the contract or agreement to provide for such additional INSURED. B. The following is added to the Section IV. General Conditions of the Common Policy Terms, Paragraph O. Other Insurance and supersedes any provision to the contrary only with respect to the Person(s) or Organization(s) shown in the Schedule above: This POLICY is primary to and will not seek contribution from any OTHER INSURANCE available to the Person(s) or Organization(s) shown in the Schedule above provided that: 18 of 18 (FJS00) ProSelect Insurance Company Activity No: MAN 002 07/14 r2 Date Produced: 12/30/2020 Page 2 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 POLICY would be primary and would not seek contribution from any OTHER INSURANCE. C. Subject to all other terms and conditions of the POLICY, the following is added to Section IV. General Conditions, paragraph Q. Subrogation of the Common Policy Terms: WE will waive any right of recovery WE may have against the person or organization shown in the Schedule above because of payments WE make for INJURY or DAMAGE arising out of YOUR WORK done under a contract with that person or organization. The waiver applies only to the person(s) or organization(s) shown in the Schedule above. D. With respect to the insurance afforded to the additional INSURED shown in the Schedule above, the following is added to Section III. Our Limit of Liability: 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 Liability shown in the DECLARATIONS; whichever is less. E. This additional INSURED shall share in the Limits of Liability of the FIRST NAMED INSURED, and this extension of coverage shall not increase OUR Limit of Liability. Nothing in this endorsement shall vary, alter, waive or extend any of the terms and conditions of the POLICY, other than as expressly stated above. Gregg L. Hanson Erin B. Bagley President & CEO Assistant Secretary