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HomeMy WebLinkAbout570102901693AT310495Holder Identifier : 7777777707070700077761616045571110766707007315446207443036662517300072651566057221130763514457167555207562515336770112075362331765267750726204551654130207724011770276512076727242035772000777777707000707007 7777777707070700073525677115456000733001407137302307033336243063000070333363420620100713223635317200107032236243173000070233363520731000703333635307310007022237253063111077756163351765540777777707000707007Certificate No :570102901693CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) 12/05/2023 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. PRODUCER Aon Risk Services Northeast, Inc. Boston MA Office 53 State Street Suite 2201 Boston MA 02109 USA PHONE(A/C. No. Ext): E-MAILADDRESS: INSURER(S) AFFORDING COVERAGE NAIC # (866) 283-7122 INSURED 22322Greenwich Insurance CompanyINSURER A: 24554XL Insurance America IncINSURER B: 37885XL Specialty Insurance CoINSURER C: 31135Great American Security Ins CoINSURER D: INSURER E: INSURER F: FAX(A/C. No.):(800) 363-0105 CONTACTNAME: American Tower Asset Sub, LLC 116 Huntington Avenue11th FloorBoston MA 02116-5786 USA COVERAGES CERTIFICATE NUMBER:570102901693 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.Limits shown are as requested POLICY EXP (MM/DD/YYYY)POLICY EFF (MM/DD/YYYY)SUBRWVDINSR LTR ADDL INSD POLICY NUMBER TYPE OF INSURANCE LIMITS COMMERCIAL GENERAL LIABILITY CLAIMS-MADE OCCUR POLICY LOC EACH OCCURRENCE DAMAGE TO RENTED PREMISES (Ea occurrence) MED EXP (Any one person) PERSONAL & ADV INJURY GENERAL AGGREGATE PRODUCTS - COMP/OP AGG X X X GEN'L AGGREGATE LIMIT APPLIES PER: $2,000,000 $1,000,000 $10,000 $2,000,000 $20,000,000 $2,000,000 A 12/01/2023 12/01/2024RGD943761411 PRO- JECT OTHER: AUTOMOBILE LIABILITY ANY AUTO OWNED AUTOS ONLY SCHEDULED AUTOS HIRED AUTOS ONLY NON-OWNED AUTOS ONLY BODILY INJURY ( Per person) PROPERTY DAMAGE (Per accident) X BODILY INJURY (Per accident) $2,000,000A12/01/2023 12/01/2024 $250,000 COMBINED SINGLE LIMIT (Ea accident) RAD9437615-11 Deductible EXCESS LIAB X OCCUR CLAIMS-MADE AGGREGATE EACH OCCURRENCE DED $10,000,000 $10,000,000 12/01/2023UMBRELLA LIABD 12/01/2024UMB5200906 RETENTION X E.L. DISEASE-EA EMPLOYEE E.L. DISEASE-POLICY LIMIT E.L. EACH ACCIDENT $1,000,000 X OTH-ERPER STATUTEB12/01/2023 12/01/2024 Workers Comp (AOS) SIR applies per policy terms & conditions C 12/01/2023 12/01/2024 $1,000,000 Y / N (Mandatory in NH) ANY PROPRIETOR / PARTNER / EXECUTIVE OFFICER/MEMBER EXCLUDED?N / AN RWR943547011 Workers Comp (Retro Ded.) WORKERS COMPENSATION AND EMPLOYERS' LIABILITY If yes, describe under DESCRIPTION OF OPERATIONS below $1,000,000 RWD943538611 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) RE: Site Number: 310495, Site Name: Bremerton- City 3, Site Address: 4780 W. Belfair Valley Rd., Bremerton, Kitsap, WA 98312-3202. Landlord and its elected and appointed officers, officials, agents, employees, representatives, engineers, consultants and volunteers are included as Additional Insured in accordance with the policy provisions of the General Liabilitypolicy. CANCELLATIONCERTIFICATE HOLDER AUTHORIZED REPRESENTATIVECity of Bremerton WAAttn: Melinda Monroe345 6th Street, Suite 600 Bremerton WA 98337 USA ACORD 25 (2016/03) ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS.