Loading...
HomeMy WebLinkAboutCity of Bremerton - WC Certificate 2020-21CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DD/YYYY) INSURER(S) AFFORDING COVERAGE NAIC # PRODUCER INSURED INSURER A : INSURER B : INSURER C : INSURER D : INSURER E : COVERAGES TYPE OF INSURANCE POLICY NUMBER LIMITS COMMERCIAL GENERAL LIABILITY CLAIMS-MADE OCCUR GEN'L AGGREGATE LIMIT APPLIES PER: LOCPOLICY OTHER: EACH OCCURRENCE MED EXP (Any one person) PERSONAL & ADV INJURY GENERAL AGGREGATE PRODUCTS - COMP/OP AGG $ $ $ $ $ $ AUTOMOBILE LIABILITY ANY AUTO $ $ $ $ OCCUR CLAIMS-MADE DED RETENTION $ EACH OCCURRENCE AGGREGATE E.L. EACH ACCIDENT E.L. DISEASE - EA EMPLOYEE E.L. DISEASE - POLICY LIMIT DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) CERTIFICATE HOLDER CANCELLATION $ $ $ $ $ Y/N CONTACTNAME:PHONE(A/C, No, Ext): E-MAILADDRESS: FAX(A/C, No): CERTIFICATE NUMBER:REVISION NUMBER: $ UMBRELLA LIAB EXCESS LIAB AUTHORIZED REPRESENTATIVE © 1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03)The ACORD name and logo are registered marks of ACORD $ INSURER F : $ N/A SCHEDULED AUTOS NON-OWNED AUTOS ONLY OWNEDAUTOS ONLY HIREDAUTOS ONLY 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 LTR ADDL INSD POLICY EFF (MM/DD/YYYY) POLICY EXP (MM/DD/YYYY) PRO- JECT DAMAGE TO RENTED PREMISES (Ea occurrence) COMBINED SINGLE LIMIT (Ea accident) BODILY INJURY (Per person) BODILY INJURY (Per accident) PROPERTY DAMAGE(Per accident) WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED?(Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below PER STATUTE OTH-ER SUBR WVD 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 rights to the certificate holder in lieu of such endorsement(s). SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. 06/25/2020 AP INTEGO INSURANCE GROUP LLC 375 WOODCLIFF DR 1ST FL FAIRPORT, NY 14450 (866) 890-9965 (866) 890-9965 (888) 733-5112 travelersselectpayrollservices@travelers.com INET INC IPARQ 1050 ROSECRANS ST STE G SAN DIEGO, CA 92106 THE CHARTER OAK FIRE INSURANCE COMPANY 583895725221771 A UB-7N584221-20 05/31/2020 05/31/2021 X 1,000,000 1,000,000 1,000,000 CITY OF BREMERTON 345 6TH ST STE 100 BREMERTON, WA 98337