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HomeMy WebLinkAbout1 - Original Submission_ Bremerton - RR (1)1/27/2022 R & R Insurance Services, Inc N14 W23900 Stone Ridge Drive Waukesha WI 53188 Amy Brennan (262)574-7000 (262)574-7080 Amy.Brennan@rrins.com Centrisys Capital Inc Centrisys Corporation 9586 58th Place Kenosha WI 53144 The Travelers Indemnity Company 25658 Travelers Property Casualty Insurance Company ofAmerica25674 Beazley Insurance Company 22-23 Liability B X Foreign Liability General Liability coverage is with a different insurance agency 6303S590226 1/1/2022 1/1/2023 Foreign Liability 1,000,000 A X X X Blkt AI PNC X X Blkt WOS BA3S590472 1/1/2022 1/1/2023 Form CAT353 0215 WOS Form CAT474 0216 AI PNC 1,000,000 B X X X 10,000 Underlying GL AL EL Foreign Form EU0001 0716 PNC WOS CUP6S258757 1/1/2022 1/1/2023 10,000,000 10,000,000 Workers Compensation coverage is with a different insurance agency C Pollution Liability incl Mold BLU15251A21 1/1/2022 1/1/2023 Each Claim/Policy Aggregate $3,000,000 C Professional Liability BLU15251A21 1/1/2022 1/1/2023 Each Claim/Policy Aggregate $3,000,000 City of Bremerton Attn: Risk Management 345 6th St Ste 100 Bremerton, WA 98337 R Kalscheuer/KM594 The ACORD name and logo are registered marks of ACORD CERTIFICATE HOLDER ©1988-2014 ACORD CORPORATION.All rights reserved. ACORD 25 (2014/01) AUTHORIZED REPRESENTATIVE CANCELLATION DATE (MM/DD/YYYY)CERTIFICATE OF LIABILITY INSURANCE LOCJECTPRO-POLICY GEN'L AGGREGATE LIMIT APPLIES PER: OCCURCLAIMS-MADE COMMERCIAL GENERAL LIABILITY PREMISES (Ea occurrence)$DAMAGE TO RENTED EACH OCCURRENCE $ MED EXP (Any one person)$ PERSONAL &ADV INJURY $ GENERAL AGGREGATE $ PRODUCTS - COMP/OP AGG $ $RETENTIONDED CLAIMS-MADE OCCUR $ AGGREGATE $ EACH OCCURRENCE $UMBRELLA LIAB EXCESS LIAB DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) INSRLTR TYPE OF INSURANCE POLICY NUMBER POLICY EFF(MM/DD/YYYY)POLICY EXP(MM/DD/YYYY)LIMITS PERSTATUTE OTH-ER E.L.EACH ACCIDENT E.L. DISEASE - EA EMPLOYEE E.L. DISEASE - POLICY LIMIT $ $ $ ANY PROPRIETOR/PARTNER/EXECUTIVE Ifyes,describe underDESCRIPTION OF OPERATIONS below (Mandatory in NH)OFFICER/MEMBER EXCLUDED? WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y / N AUTOMOBILE LIABILITY ANY AUTO ALL OWNED SCHEDULED HIRED AUTOS NON-OWNEDAUTOSAUTOS AUTOS COMBINED SINGLE LIMIT BODILY INJURY (Per person) BODILY INJURY (Per accident) PROPERTY DAMAGE $ $ $ $ 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. INSD ADDL WVD SUBR N / A $ $ (Ea accident) (Per accident) OTHER: 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 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). COVERAGES CERTIFICATE NUMBER:REVISION NUMBER: INSURED PHONE(A/C, No, Ext): PRODUCER ADDRESS:E-MAIL FAX(A/C, No): CONTACTNAME: NAIC # INSURER A : INSURER B : INSURER C : INSURER D : INSURER E : INSURER F : INSURER(S)AFFORDING COVERAGE SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. INS025 (201401) DocuSign Envelope ID: E2FE4327-F580-4703-9B7D-010B9F434D6A SHOULD 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 2/9/2022 Starr Insurance Group5005W.Loomis Rd.Greenfield WI 53220 Britta Schmidt 414-421-3800 414-421-6145 info@starrgroup.com Twin City Fire Insurance Co 29459 CENTR-3 The Hartford 29459CentrisysCorporationGaryStinson958658thPlaceKenoshaWI53144 653388779 B X 1,000,000 X 300,000 10,000 1,000,000 2,000,000 X 83 UEN OH3038 1/1/2022 1/1/2023 2,000,000 A X N 83 WE OH3037 1/1/2022 1/1/2023 1,000,000 1,000,000 1,000,000 City of Bremerton is hereby listed as additional insured as respects work performed by the named insured when required by written contract per the attachedforms.A waiver of subrogation applies in favor of the additional insured on the General Liability and Workers Compensation policies. City of BremertonAttn:Risk Management3458thSt.,Suite 100BremertonWA98337 DocuSign Envelope ID: E2FE4327-F580-4703-9B7D-010B9F434D6A The insurance afforded herein for any A person or organization is an additional insured subsidiary not named in this Coverage Part under this provision only for that period of time as a named insured does not apply to injury required by the contract or agreement. or damage with respect to which such insured However, no such person or organization is anis also a named insured under another policy insured under this provision if such person oror would be a named insured under such organization is included as an insured by anpolicy but for its termination or the exhaustion endorsement issued by us and made a part ofofits limits ofinsurance.this Coverage Part. 3. Newly Acquired Or Formed Organization a. Vendors Any organization you newly acquire or form,Any person(s) or organization(s) (referred toother than a partnership, joint venture or limited below as vendor), but only with respect toliability company, and over which you maintain "bodily injury" or "property damage" arisingfinancial interest of more than 50% of the voting out of "your products" which are distributed orstock, will qualify as a Named Insured if there is sold in the regular course of the vendor'sno other similar insurance available to that business and only if this Coverage Partorganization. However:provides coverage for "bodily injury" or a.Coverage under this provision is afforded only "property damage" included within the until the 180th day after you acquire or form "products-completed operations hazard". the organization or the end of the policy (1)The insurance afforded the vendor isperiod, whichever is earlier;subject to the following additional b.Coverage A does not apply to "bodily injury"exclusions: or "property damage" that occurred before This insurance does not apply to:you acquired or formed the organization; and (a)"Bodily injury" or "property damage" forc.Coverage B does not apply to "personal and which the vendor is obligated to payadvertising injury" arising out of an offense damages by reason of the assumptioncommitted before you acquired or formed the of liability in a contract or agreement.organization.This exclusion does not apply to 4. Nonowned Watercraft liability for damages that the vendor would have in the absence of theWith respect to watercraft you do not own that is contract or agreement;less than 51 feet long and is not being used to (b)Any express warranty unauthorized bycarry persons for a charge, any person is an insured while operating such watercraft with your you; permission. Any other person or organization (c)Any physical or chemical change in theresponsible for the conduct of such person is product made intentionally by thealso an insured, but only with respect to liability vendor;arising out of the operation of the watercraft, and (d)Repackaging, except when unpackedonly if no other insurance of any kind is available solely for the purpose of inspection,to that person or organization for this liability.demonstration, testing, or theHowever, no person or organization is an insured substitution of parts under instructionswith respect to:from the manufacturer, and then a."Bodily injury" to a co-"employee" of the repackaged in the original container; person operating the watercraft; or (e)Any failure to make such inspections, b."Property damage" to property owned by,adjustments, tests or servicing as the rented to, in the charge of or occupied by you vendor has agreed to make or normally or the employer of any person who is an undertakes to make in the usual insured under this provision.course of business, in connection with the distribution or sale ofthe products;5. Additional Insureds When Required By Written Contract, Written Agreement Or (f)Demonstration, installation, servicing Permit or repair operations, except such operations performed at the vendor'sThe following person(s) or organization(s) are an premises in connection with the sale ofadditional insured when you have agreed,in a the product;written contract, written agreement or because of (g)Products which, after distribution ora permit issued by a state or political subdivision, that such person or organization be added as an sale by you, have been labeled or additional insured on your policy, provided the relabeled or used as a container, part injury or damage occurs subsequent to the or ingredient of any other thing or execution of the contract or agreement.substance by or for the vendor; or Page 12 of 21 HG 00 01 09 16 CGL AI Policy #83 UEN OH3038DocuSign Envelope ID: E2FE4327-F580-4703-9B7D-010B9F434D6A (h)"Bodily injury" or "property damage"omissions ofthose acting on your behalf: arising out ofthe sole negligence of the (1)In connection with your premises; orvendor for its own acts or omissions or (2)In the performance of your ongoing those of its employees or anyone else operations performed by you or on your acting on its behalf. However, this behalf.exclusion does not apply to:With respect to the insurance afforded these (i)The exceptions contained in Sub-additional insureds, the following additional paragraphs (d)or (f); or exclusion applies:(ii)Such inspections, adjustments,This insurance does not apply to "bodily tests or servicing as the vendor has injury", "property damage" or "personal and agreed to make or normally advertising injury" arising out of the rendering undertakes to make in the usual of or the failure to render any professional course of business, in connection services by or for you, including:with the distribution or sale of the 1.The preparing, approving, or failing to products.prepare or approve, maps, shop drawings, (2)This insurance does not apply to any opinions, reports, surveys, field orders, insured person or organization, from change orders or drawings and whom you have acquired such products, specifications; oror any ingredient, part or container, 2.Supervisory, inspection, architectural or entering into, accompanying or containing engineering activities.such products. This exclusion applies even if the claimsb. Lessors Of Equipment against any insured allege negligence or (1)Any person(s) or organization(s) from other wrongdoing in the supervision, hiring, whom you lease equipment; but only with employment, training or monitoring of othersrespect to their liability for "bodily injury", by that insured, if the "occurrence" which "property damage" or "personal and caused the "bodily injury" or "property advertising injury" caused, in whole or in damage", or the offense which caused the part, by your maintenance, operation or "personal and advertising injury", involved the use of equipment leased to you by such rendering of or the failure to render any person(s) or organization(s). professional services by or for you.(2)With respect to the insurance afforded to e. Permits Issued By State Or Political these additional insureds this insurance Subdivisionsdoes not apply to any "occurrence" which Any state or political subdivision, but only with takes place after the equipment lease respect to operations performed by you or on expires. your behalf for which the state or political c. Lessors Of Land Or Premises subdivision has issued a permit. Any person or organization from whom you With respect to the insurance afforded theselease land or premises, but only with respect additional insureds, this insurance does not to liability arising out of the ownership, apply to:maintenance or use of that part of the land or (1)"Bodily injury", "property damage" orpremises leased to you."personal and advertising injury" arising With respect to the insurance afforded these out of operations performed for the state additional insureds the following additional or municipality; orexclusions apply:(2)"Bodily injury" or "property damage"This insurance does not apply to:included within the "products-completed 1.Any "occurrence" which takes place after operations hazard".you cease to lease that land; or f. Any Other Party2.Structural alterations, new construction or Any other person or organization who is not demolition operations performed by or on an additional insured under Paragraphs a.behalf ofsuch person or organization.through e. above, but only with respect to d. Architects, Engineers Or Surveyors liability for "bodily injury", "property damage" Any architect, engineer, or surveyor, but only or "personal and advertising injury" caused, in with respect to liability for "bodily injury", whole or in part, by your acts or omissions or "property damage" or "personal and the acts or omissions of those acting on your advertising injury" caused, in whole or in part, behalf: by your acts or omissions or the acts or (1)In the performance of your ongoing operations; HG 00 01 09 16 Page 13 of 21 DocuSign Envelope ID: E2FE4327-F580-4703-9B7D-010B9F434D6A (2)In connection with your premises owned No person or organization is an insured with respect by or rented to you; or to the conduct of any current or past partnership, joint venture or limited liability company that is not (3)In connection with "your work" and shown as a Named Insured in the Declarations. included within the "products-completed SECTION III - LIMITS OF INSURANCE operations hazard", but only if (a)The written contract or agreement 1. The Most We Will Pay requires you to provide such coverage The Limits of Insurance shown in the to such additional insured; and Declarations and the rules below fix the most we (b)This Coverage Part provides coverage will pay regardless ofthe number of: for "bodily injury" or "property damage"a.Insureds; included within the "products-b.Claims made or "suits" brought; or completed operations hazard". c.Persons or organizations making claims orHowever:bringing "suits". (1)The insurance afforded to such additional 2. General Aggregate Limitinsured only applies to the extent The General Aggregate Limit is the most we will permitted by law; and pay for the sum of:(2)If coverage provided to the additional a.Medical expenses under Coverage C;insured is required by a contract or agreement, the insurance afforded to such b.Damages under Coverage A,except additional insured will not be broader than damages because of "bodily injury" or that which you are required by the contract "property damage" included in the "products-or agreement to provide for such completed operations hazard"; and additional insured.c.Damages under Coverage B. With respect to the insurance afforded to 3. Products-Completed Operations Aggregate these additional insureds, this insurance does Limitnot apply to: The Products-Completed Operations Aggregate "Bodily injury", "property damage" or Limit is the most we will pay under Coverage A"personal and advertising injury" arising out of for damages because of "bodily injury" and the rendering of, or the failure to render, any "property damage" included in the "products-professional architectural, engineering or completed operations hazard". surveying services, including:4. Personal And Advertising Injury Limit(1)The preparing, approving, or failing to Subject to 2.above, the Personal and prepare or approve, maps, shop drawings, Advertising Injury Limit is the most we will pay opinions, reports, surveys, field orders, under Coverage B for the sum of all damageschange orders or drawings and because of all "personal and advertising injury"specifications; or sustained by any one person or organization. (2)Supervisory, inspection, architectural or 5. Each Occurrence Limitengineering activities. Subject to 2.or 3.above, whichever applies, the This exclusion applies even if the claims Each Occurrence Limit is the most we will pay for against any insured allege negligence or the sum of:other wrongdoing in the supervision, hiring, employment, training or monitoring of others a.Damages under Coverage A;and by that insured, if the "occurrence" which b.Medical expenses under Coverage Ccaused the "bodily injury" or "property because of all "bodily injury" and "property damage", or the offense which caused the damage" arising out ofany one "occurrence". "personal and advertising injury", involved the rendering of or the failure to render any 6. Damage To Premises Rented To You Limit professional services by or for you.Subject to 5.above, the Damage To PremisesThe limits of insurance that apply to additional Rented To You Limit is the most we will pay insureds is described in Section III - Limits Of under Coverage A for damages because of Insurance. "property damage" to any one premises, while rented to you, or in the case of damage by fire, How this insurance applies when other insurance lightning or explosion, while rented to you or is available to the additional insured is described temporarily occupied by you with permission of in the Other Insurance Condition in Section IV -the owner. Commercial General Liability Conditions. Page 14 of 21 HG 00 01 09 16 DocuSign Envelope ID: E2FE4327-F580-4703-9B7D-010B9F434D6A DocuSign Envelope ID: E2FE4327-F580-4703-9B7D-010B9F434D6A DocuSign Envelope ID: E2FE4327-F580-4703-9B7D-010B9F434D6A THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. Countersigned by Authorized Representative Form WC 00 03 13 Printed in U.S.A. Policy Expiration Date: 01/01/23 WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT Endorsement Number:Policy Number: 83 WE OH3037 Effective Date: 01/01/22 Effective hour is the same as stated on the Information Page of the policy. Named Insured and Address:CENTRISYS CORPORATION 9586 58TH PL KENOSHA WI 53144 We have the right to recover our payments from anyone liable for an injury covered by this policy. We will not enforce our right against the person or organization named in the Schedule. This agreement shall not operate directly or indirectly to benefit anyone not named in the Schedule. SCHEDULE Any person or organization from whom you are required by contract or agreement to obtain this waiver from us. Endorsement is not applicable in KY, NH, NJ or for any MO construction risk DocuSign Envelope ID: E2FE4327-F580-4703-9B7D-010B9F434D6A