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HomeMy WebLinkAboutCity of Bremerton COISHOULD 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 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. $ $ $ $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 belowIf 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 HIREDAUTOS ONLY U OS  0DUVK 0F/HQQDQ $JHQF\ //& : WK $YH 6XLWH $QFKRUDJH $.  -DPLH (VTXLYHO  MDPLHHVTXLYHO#PDUVKPPDFRP /LFHQVH (YDQVWRQ ,QVXUDQFH &RPSDQ\ %5,67%$<=XULFK $PHULFDQ ,QVXUDQFH &RPSDQ\3HWUR&DUG ,QF 6 &HQWUDO $YHQXH.HQW :$  1DYLJDWRUV 6SHFLDOW\ ,QVXUDQFH &RPSDQ\ $PHULFDQ =XULFK ,QVXUDQFH &RPSDQ\  $; ;    ; <<0./9(19  % ; <<%$3 &$; ; </$(;&,&0./9(8( '; 1 <:&    $3ROOXWLRQ3URIHVVLRQDO 0./9(193HU &ODLP$JJUHJDWH  5H (YLGHQFH RI ,QVXUDQFH 6XEMHFW WR VDLG SROLF\ OLPLWV WHUPV DQG H[FOXVLRQV :KHUH UHTXLUHG E\ ZULWWHQ FRQWUDFW &HUWLILFDWH +ROGHU LV DQ $GGLWLRQDO ,QVXUHG RQWKH *HQHUDO /LDELOLW\ DQG $XWR /LDELOLW\ SROLFLHV VXEMHFW WR WKH WHUPV FRQGLWLRQV DQG OLPLWDWLRQV RI VDLG SROLFLHV DQG WKH DGGLWLRQDO LQVXUHG HQGRUVHPHQW :KHUHUHTXLUHG E\ ZULWWHQ FRQWUDFW :DLYHU RI 6XEURJDWLRQ LQ IDYRU RI &HUWLILFDWH +ROGHU DSSOLHV WR UHIHUHQFHG SROLFLHV VXEMHFW WR WKH WHUPV FRQGLWLRQV DQG OLPLWDWLRQV RIVDLG SROLFLHV DQG WKH :DLYHU RI 6XEURJDWLRQ HQGRUVHPHQW ,W LV IXUWKHU DJUHHG WKDW ZKHUH UHTXLUHG E\ ZULWWHQ FRQWUDFW WKH *HQHUDO /LDELOLW\ DQG $XWR /LDELOLW\LQVXUDQFH DV LV DIIRUGHG WKH &HUWLILFDWH +ROGHU VKDOO EH SULPDU\ DQG QRQ FRQWULEXWRU\ ZLWK DQ\ RWKHU LQVXUDQFH LQ IRUFH IRU RU ZKLFK PD\ EH SXUFKDVHG E\WKH&HUWLILFDWH +ROGHU &LW\ RI %UHPHUWRQ)LQDQFLDO 6HUYLFHV 6L[WK 6WUHHW6XLWH %UHPHUWRQ :$  ADDITIONAL REMARKS SCHEDULE Page of AGENCY NAMED INSURED CARRIER NAIC CODE EFFECTIVE DATE: ADDITIONALREMARKS THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, FORM NUMBER: FORM TITLE: ACORD 101 (2008/01)© 2008 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD 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. Certificate of Liability25 3HWUR&DUG ,QF0DUVK 0F/HQQDQ $JHQF\ //&