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HomeMy WebLinkAboutRFM COI 3-1-25ANY PROPRIETOR/PARTNER/EXECUTIVEOFFICER/MEMBER EXCLUDED? INSR ADDL SUBRLTRINSDWVD PRODUCER CONTACTNAME: FAXPHONE(A/C, No):(A/C, No, Ext): E-MAILADDRESS: INSURER A : INSURED INSURER B : INSURER C : INSURER D : INSURER E : INSURER F : POLICY NUMBER POLICY EFF POLICY EXPTYPE OF INSURANCE LIMITS(MM/DD/YYYY)(MM/DD/YYYY) AUTOMOBILE LIABILITY UMBRELLA LIAB EXCESS LIAB WORKERS COMPENSATION AND EMPLOYERS' LIABILITY DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) AUTHORIZED REPRESENTATIVE EACH OCCURRENCE $ DAMAGE TO RENTEDCLAIMS-MADE OCCUR $PREMISES (Ea occurrence) MED EXP (Any one person)$ PERSONAL & ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER:GENERAL AGGREGATE $ PRO-POLICY LOC PRODUCTS - COMP/OP AGGJECT OTHER:$ COMBINED SINGLE LIMIT $(Ea accident) ANY AUTO BODILY INJURY (Per person)$ OWNED SCHEDULED BODILY INJURY (Per accident)$AUTOS ONLY AUTOS HIRED NON-OWNED PROPERTY DAMAGE $AUTOS ONLY AUTOS ONLY (Per accident) $ OCCUR EACH OCCURRENCE CLAIMS-MADE AGGREGATE $ DED RETENTION$ PER OTH-STATUTE ER E.L. EACH ACCIDENT E.L. DISEASE - EA EMPLOYEE $ If yes, describe under E.L. DISEASE - POLICY LIMITDESCRIPTION OF OPERATIONS below INSURER(S) AFFORDING COVERAGE NAIC # COMMERCIAL GENERAL LIABILITY Y / N N / A (Mandatory in NH) SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. 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. 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). COVERAGES CERTIFICATE NUMBER:REVISION NUMBER: CERTIFICATE HOLDER CANCELLATION © 1988-2015 ACORD CORPORATION. All rights reserved.ACORD 25 (2016/03) CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DD/YYYY) $ $ $ $ $ The ACORD name and logo are registered marks of ACORD 2/12/2024 (253) 330-8955 (253) 473-5363 24066 Rice-Fergus-Miller, Inc. 275 5th Street, Suite 100 Bremerton, WA 98337 24082 24074 A 2,000,000 X X BZA55354881 3/1/2024 3/1/2025 15,000 2,000,000 4,000,000 4,000,000 1,000,000B X X BAS55354881 3/1/2024 3/1/2025 4,000,000C USO55354881 3/1/2024 3/1/2025 10,000 4,000,000 RE: Project #315012 ~ Quincy Square on 4th Operations of the named insured: See attached Form BP7996 for additional insured and Waiver of Subrogation form BP0497, Stop Gap form BP0674 and Auto additional insured and waiver of subrogation form AC8501 City of Bremerton Public Works and Utilities 100 Oyster Bay Ave N Bremerton, WA 98312 RICEINC-01 COMFO1 Fournier 5712 Orchard St. W. University Place, WA 98467 Krystal Edwards krystale@fournierinsurance.com American Fire and Casualty Company Ohio Security Insurance Company The Ohio Casualty Insurance Company X X X X 117 180of553548810047702352000000 2000000 2000000 POLICY NUMBER:BUSINESSOWNERS BP 06 74 07 13 THIS ENDORSEMENT CHANGES THE POLICY. PLEASEREAD IT CAREFULLY. WASHINGTON - STOP GAP - EMPLOYER’S LIABILITY COVERAGE This endorsement modifies insurance provided under the following: BUSINESSOWNERS COVERAGEFORM BP 06 74 07 13 Insurance Services Office, Inc., 2012 Page 1 of 5 SCHEDULE Bodily Injury By Accident Bodily Injury By Disease Each Accident Each Employee Aggregate $$$ Information required to complete this Schedule, if not shown above, will be shown in the Declarations. Section II - Liability is amended as follows: A. Coverage - Stop Gap - Employer’s Liability 1. Insuring Agreement a.We will pay those sums that the in- sured becomes legally obligated by Washington law to pay as damages because of "bodily injury by acci- dent" or "bodily injury by disease" to your "employee" to which this in- surance applies. We will have the right and duty to defend the insured against any "suit" seeking those damages. However, we will have no duty to defend the insured against any "suit" seeking damages to which this insurance does not apply. We may, at our discretion, investigate any accident and settle any claim or "suit" that may result. But: (1)The amount we will pay for dam- ages is limited as described in Paragraph D.Liability And Medi- cal Expenses Limits Of Insur- ance; and (2)Our right and duty to defend end when we have used up the ap- plicable Limit of Insurance in the payment of judgments or settle- ments under this coverage. No other obligation or liability to pay sums or perform acts or services is covered unless explicitly provided for under Supplementary Payments. b.This insurance applies to "bodily in- jury by accident" or "bodily injury by disease" only if: (1)The: (a)"Bodily injury by accident" or "bodily injury by disease" takes place in the "coverage territory"; (b)"Bodily injury by accident" or "bodily injury by disease" arises out of and in the course of the injured "em- ployee’s" employment by you; and (c)"Employee", at the time of the injury, was covered un- der a workers’ compensa- tion policy and subject to a "workers’ compensation law" of Washington; and (2)The: (a)"Bodily injury by accident" is caused by an accident that occurs during the policy pe- riod; or (b)"Bodily injury by disease" is caused by or aggravated by conditions of employment by you, and the injured "em- ployee’s" last day of last ex- posure to the conditions causing or aggravating such "bodily injury by disease" occurs during the policy pe- riod. 118 180ofBP 06 74 07 13 Insurance Services Office, Inc., 2012 Page 2 of 5 c.The damages we will pay, where re- covery is permitted by law, include damages: (1)For: (a)Which you are liable to a third party by reason of a claim or "suit" against you by that third party to recover the damages claimed against such third party as a result of injury to your "em- ployee"; (b)Care and loss of services; and (c)Consequential "bodily injury by accident" or "bodily in- jury by disease" to a spouse, child, parent, brother or sis- ter of the injured "employ- ee"; provided that these damages are the direct consequence of "bod- ily injury by accident" or "bodily injury by disease" that arises out of and in the course of the in- jured "employee’s" employment by you; and (2)Because of "bodily injury by ac- cident" or "bodily injury by dis- ease" to your "employee" that arises out of and in the course of employment, claimed against you in a capacity other than as employer. 2. Exclusions Applicable To Stop Gap - Em- ployer’s Liability Coverage This insurance does not apply to: a. Intentional Injury "Bodily injury by accident" or "bod- ily injury by disease" intentionally caused or aggravated by you, or "bodily injury by accident" or "bod- ily injury by disease" resulting from an act which is determined to have been committed by you if it is rea- sonable to believe that an injury is substantially certain to occur. b. Fines Or Penalties Any assessment, penalty or fine levied by any regulatory inspection agency or authority. c. Statutory Obligations Any obligation of the insured under a workers’ compensation, disability benefits or unemployment compen- sation law or any similar law. d. Contractual Liability Liability assumed by you under any contract or agreement. e. Violation Of Law "Bodily injury by accident" or "bod- ily injury by disease" suffered or caused by any employee while em- ployed in violation of law with your actual knowledge or the actual knowledge of any of your "executive officers". f. Termination, Coercion Or Discrimi- nation Damages arising out of coercion, criticism, demotion, evaluation, reassignment, discipline, defama- tion, harassment, humiliation, dis- crimination against or termination of any "employee", or arising out of other employment or personnel de- cisions concerning the insured. g. Failure To Comply With Workers’ Compensation Law "Bodily injury by accident" or "bod- ily injury by disease" to an "employ- ee" when you are: (1)Deprived of common law defenses; or (2)Otherwise subject to penalty; because of your failure to secure your obligations or other failure to comply with any "workers’ compen- sation law". h. Violation Of Age Laws Or Employ- ment Of Minors "Bodily injury by accident" or "bod- ily injury by disease" suffered or caused by any person: (1)Knowingly employed by you in violation of any law as to age; or (2)Under the age of 14 years, re- gardless of any such law. 119 180of55354881004770235BP 06 74 07 13 Insurance Services Office, Inc., 2012 Page 3 of 5 i. Federal Laws Any premium, assessment, penalty, fine, benefit, liability or other obliga- tion imposed by or granted pursuant to: (1)The Federal Employer’s Liability Act (45 USC Sections 51-60); (2)The Nonappropriated Fund In- strumentalities Act (5 USC Sec- tions 8171-8173); (3)The Longshore and Harbor Workers’ Compensation Act (33 USC Sections 910-950); (4)The Outer Continental Shelf Lands Act (43 USC Sections 1331-1356); (5)The Defense Base Act (42 USC Sections 1651-1654); (6)The Federal Coal Mine Health and Safety Act of 1969 (30 USC Sections 901-942); (7)The Migrant and Seasonal Agri- cultural Worker Protection Act (29 USC Sections 1801-1872); (8)Any other workers’ compensa- tion, unemployment compensa- tion or disability laws or any similar law; or (9)Any subsequent amendments to the laws listed above. j. Punitive Damages Multiple, exemplary or punitive dam- ages. k. Crew Members "Bodily injury by accident" or "bod- ily injury by disease" to a master or member of the crew of any vessel or any member of the flying crew of an aircraft. B.The Coverage Extension - Supplementary Payments provisions apply to Stop Gap - Em- ployer’s Liability Coverage as well as to Busi- ness Liability Coverage. C.For the purposes of this endorsement, Para- graph C. Who Is An Insured is replaced by the following: C. Who Is An Insured If you are designated in the Declarations as: 1.An individual, you and your spouse are insureds, but only with respect to the conduct of a business of which you are the sole owner. 2.A partnership or joint venture, you are an insured. Your members, your partners and their spouses are also insureds, but only with respect to the conduct of your business. 3.A limited liability company, you are an insured. Your members are also insureds, but only with respect to the conduct of your business. Your man- agers are insureds, but only with re- spect to their duties as your manag- ers. 4.An organization other than a partnership, joint venture or limited liability company, you are an in- sured. Your "executive officers" and directors are insureds, but only with respect to their duties as your offi- cers or directors. Your stockholders are also insureds, but only with re- spect to their liability as stockholders. 5.A trust, you are an insured. Your trustees are also insureds, but only with respect to their duties as trust- ees. No person or organization is an insured with respect to the conduct of any current or past partnership, joint venture or limit- ed liability company that is not shown as a Named Insured in the Declarations. D.For the purposes of this endorsement, Para- graph D. Liability And Medical Expenses Lim- its Of Insurance is replaced by the following: D. Liability And Medical Expenses Limits Of Insurance 1.The Limits Of Insurance shown in the Schedule of this endorsement and the rules below fix the most we will pay regardless of the number of: a.Insureds; b.Claims made or "suits" brought; or c.Persons or organizations making claims or bringing "suits". 2.The "Bodily Injury By Accident" - Each Accident Limit shown in the Schedule of this endorsement is the most we will pay for all damages covered by this insurance because of "bodily injury by accident" to one or more "employees" in any one acci- dent. 120 180ofBP 06 74 07 13 Insurance Services Office, Inc., 2012 Page 4 of 5 3.The "Bodily Injury By Disease" - Ag- gregate Limit shown in the Schedule of this endorsement is the most we will pay for all damages covered by this insurance and arising out of "bodily injury by disease", regard- less of the number of "employees" who sustain "bodily injury by dis- ease". 4.Subject to Paragraph D.3.of this endorse- ment, the "Bodily Injury By Disease" - Each "Employee" Limit shown in the Schedule of this endorsement is the most we will pay for all damages because of "bodily injury by disease" to any one "employee". The limits of the coverage apply separately to each consecutive annual period and to any remaining period of less than 12 months, starting with the beginning of the policy pe- riod shown in the Declarations, unless the policy period is extended after issuance for an additional period of less than 12 months. In that case, the additional period will be deemed part of the last preceding period for purposes of determining the Limits of Insur- ance. E.For the purposes of this endorsement, Con- dition 2. Duties In The Event Of Occurrence, Offense, Claim Or Suit of the Liability And Medical Expenses General Conditions is re- placed by the following: 2. Duties In The Event Of Injury, Claim Or Suit a.You must see to it that we or our agent is notified as soon as practica- ble of a "bodily injury by accident" or "bodily injury by disease" which may result in a claim. To the extent possible, notice should include: (1)How, when and where the "bod- ily injury by accident" or "bodily injury by disease" took place; (2)The names and addresses of any injured persons and witnesses; and (3)The nature and location of any injury. b.If a claim is made or "suit" is brought against any insured, you must: (1)Immediately record the specifics of the claim or "suit" and the date received; and (2)Notify us as soon as practicable. You must see to it that we receive written notice of the claim or "suit" as soon as practicable. c.You and any other involved insured must: (1)Immediately send us copies of any demands, notices, sum- monses or legal papers received in connection with the injury, claim, proceeding or "suit"; (2)Authorize us to obtain records and other information; (3)Cooperate with us and assist us, as we may request, in the inves- tigation or settlement of the claim or defense against the "suit"; (4)Assist us, upon our request, in the enforcement of any right against any person or organiza- tion which may be liable to the insured because of injury to which this insurance may also apply; and (5)Do nothing after an injury occurs that would interfere with our right to recover from others. d.No insured will, except at that in- sured’s own cost, voluntarily make a payment, assume any obligation, or incur any expense, other than for first aid, without our consent. F.For the purposes of this endorsement, Para- graph 4.of the Liability And Medical Ex- penses Definitions section is replaced by the following: 4."Coverage territory" means: a.The United States of America (in- cluding its territories and posses- sions), Puerto Rico and Canada; b.International waters or airspace, but only if the injury or damage occurs in the course of travel or transportation between any places included in a. above; or c.All other parts of the world if the in- jury or damage arises out of the ac- tivities of a person whose home is in the territory described in a.above, but who is away for a short time on your business; 121 180of55354881004770235BP 06 74 07 13 Insurance Services Office, Inc., 2012 Page 5 of 5 provided the insured’s responsibility to pay damages is determined in the United States (including its territories and pos- sessions), Puerto Rico, or Canada, in a suit on the merits according to the sub- stantive law in such territory, or in a set- tlement we agree to. G.The following are added to the Liability And Medical Expenses Definitions section: 1."Workers’ compensation law" means the Workers’ Compensation Law and any Oc- cupational Disease Law of Washington. This does not include provisions of any law providing nonoccupational disability benefits. 2."Bodily injury by accident" means bodily injury, sickness or disease sustained by a person, including death, resulting from an accident. A disease is not "bodily in- jury by accident" unless it results directly from "bodily injury by accident". 3."Bodily injury by disease" means a dis- ease sustained by a person, including death. "Bodily injury by disease" does not include a disease that results directly from an accident. H.For the purposes of this endorsement, the definition of "bodily injury" does not apply.