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HomeMy WebLinkAboutcert_CHI_City of Bremerton_10032278_1SHOULD 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 B 212-948-0811 1,000,000 10/01/2022 GLO541569308 X CHI-010032278-01 1,000,000 1,000,000 WC 7296413-01 (WI) X 26247 1,000,000 SIR: N X10/01/2021 7 10/01/2022 09/30/2021 10/01/2022 StLouis.CertRequest@Marsh.Com BAP 7296414-01 Professional Liability A 2,000,000 1,000,000 X 26387 American Guarantee & Liability Ins Co 1,000,000 X C X coverage applies as primary and non-contributory where required by written contract. Umbrella Liability is Follow Form of General Liability, Automobile Liability and Employers Liability subject to policy terms, 03/04/2022 1,000,000 10/01/2021 1,000,000 RE: Construction Materials Testing and Special Inspection Services Kitsap Way (SR310) and Warren Avenue/Wheaton Way (SR303) Bremerton, Washington / PSI Proposal Number 0742-351924 X 10/01/2021 Bremerton, WA 98337-1891 City of Bremerton City of Bremerton is included as additional insured (except as respects all coverage afforded by the Workers' Compensation and Professional Liability policies) as required by written contract. The General Liability conditions and exclusions. A Steadfast Insurance Company CN102792561-PSI-Prof-21-22 Each Claim/Aggregate: 20,000 10/01/2022 1,000,000 AUC541569408 A 2,000,000 16535 100,000 1,000,000 09/30/2022 X WC 7296412-01 (AOS) 800 Market Street, Suite 1800 Marsh USA, Inc. X St. Louis, MO 63101 3011 S Huson Street, Suite A Professional Service Industries, Inc. Tacoma, WA 98409 X EOC0206920-06 10/01/2021 345 6th Street, Suite 100 10/01/2021 A Marsh | U.S. Operations 10/01/2022 866-966-4664 Zurich American Insurance Company 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: Midwest Engineering Services, Inc. �� �� 22 Professional Service Industries Holdings, Inc.�� aka PSI�� St. Louis Testing Holdings USA Inc.�� � dba Intertek-PSI�� Professional Service Industries, Inc.�� �� �� Named Insured under General Liability, Auto Liability, Workers Compensation, Umbrella/Excess Liability and Professional Liability Includes:� � Certificate of Liability Insurance CN102792561 Professional Service Industries Enigeerings, PLLC�� PSI Acquisitions, Inc.�� Wilson Inspection X-Ray Services, Inc.��� The Additional Insured(s) are granted a Waiver of Subrogation where required by written contract, but only for liability arising out of the operations of the Named Insured. �� Marsh USA, Inc.� 3011 S Huson Street, Suite A� Professional Service Industries, Inc.� Tacoma, WA 98409 25 Pittsburgh Testing Laboratory, Inc.��