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HomeMy WebLinkAbout3 - Legal Review Submission_ CityofBremertonWA_W24110710SHOULD 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) © 1988-2016 ACORD CORPORATION. All rights reserved. CERTIFICATE HOLDER The ACORD name and logo are registered marks of ACORD HIREDAUTOS ONLY Willis Towers Watson Midwest, Inc.c/o 26 Century BlvdP.O. Box 305191Nashville, TN 372305191 USA Michels Corporation1715 16th St SESalem, OR 97302 SEE ATTACHED City of Bremerton, WA100 Oyster Bay Ave NBremerton, WA 98312 03/09/2022 1-877-945-7378 1-888-467-2378 certificates@willis.com Greenwich Insurance Company 22322 XL Insurance America Inc XL Specialty Insurance Company 24554 37885 AIG Specialty Insurance Company 26883 W24110710 A 3,000,000 1,000,000 3,000,000 6,000,000 6,000,000 Y Y CGD740955305 02/01/2022 02/01/2023 A 5,000,000 02/01/202302/01/2022CAD740955405 B 10,000,000 US00077661LI22A 02/01/2022 02/01/2023 10,000,000 CWD740955105C 1,000,000No02/01/2022 02/01/2023 1,000,000 1,000,000 C Workers Compensation - WI and Employers Liability E.L. Each AccidentCWR74095520502/01/2022 02/01/2023 E.L. Disease-Each Emp Work Comp: Per Statute E.L. Disease-Pol Lmt 244053622312907SR ID:BATCH: $1,000,000 $1,000,000 $1,000,000 Willis Towers Watson Certificate Center Page 1 of 2DocuSign Envelope ID: D7D3EB76-55F8-4FDA-94AA-EFF9DAA18C10 ACORD 101 (2008/01) The ACORD name and logo are registered marks of ACORD © 2008 ACORD CORPORATION. All rights reserved. THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, FORM NUMBER:FORM TITLE: ADDITIONAL REMARKS ADDITIONAL REMARKS SCHEDULE Page of AGENCY CUSTOMER ID: LOC #: AGENCY CARRIER NAIC CODE POLICY NUMBER NAMED INSURED EFFECTIVE DATE: Michels Corporation1715 16th St SESalem, OR 97302 Project Name/#/Description: 22010606-2022 Sewer Rehabilitation Project Address/Location: Bremerton WA City of Bremerton, WA is Additional Insured with respect to the General Liability coverage and the work performed bythe Named Insured when required by written contract, agreement or permit executed prior to loss. Such insurance as is afforded to Additional Insured shall be Primary and Non-contributory with any other insuranceavailable to Additional Insured if required by contract executed prior to loss. Waiver of Subrogation applies in favor of Additional Insured with respects to General Liability. INSURER AFFORDING COVERAGE: AIG Specialty Insurance Company NAIC#: 26883POLICY NUMBER: CPO 8197229 EFF DATE: 02/01/2022 EXP DATE: 02/01/2023 TYPE OF INSURANCE: LIMIT DESCRIPTION: LIMIT AMOUNT:Contractors Pollution Each Loss $5,000,000 Aggregate $5,000,000 2 2 Willis Towers Watson Midwest, Inc. See Page 1 See Page 1 See Page 1 See Page 1 25 Certificate of Liability Insurance W24110710CERT:2440536BATCH:22312907SR ID: DocuSign Envelope ID: D7D3EB76-55F8-4FDA-94AA-EFF9DAA18C10