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HomeMy WebLinkAboutCityofBremerton_W28461342SHOULD 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 Northeast, Inc.c/o 26 Century BlvdP.O. Box 305191Nashville, TN 372305191 USA Crown Castle Inc. f/k/a Crown Castle International Corp.See Attached Named Insured List8020 Katy FreewayHouston, TX 77024 BU#846273 - KITSAP LAKE, 9002 W Werner Rd., BREMERTON, WA 98312 (AT&T: FA# 10092156) City of Bremerton, and its elected and appointed officers, officials, agents, employees, representatives, engineers,consultants, and volunteers are included as Additional Insureds under the General Liability, Automobile Liability, andUmbrella/Excess Liability as their interest may appear and as required by written agreement and only with respect tothe liability arising out of the operations performed by or on behalf of the Named Insured. City of BremertonAttn: Public Works & UtilitiesAdministrative Manager3027 Olympus DriveBremerton, WA 98310-4799 03/27/2023 COIRequest@crowncastle.com Continental Casualty Company 20443 Berkshire Hathaway Specialty Insurance Com Continental Insurance Company 22276 35289 W28461342 A 2,000,000 1,000,000 10,000 2,000,000 4,000,000 4,000,000 Y Y 7018331477 04/01/2023 04/01/2024 A 2,000,000 04/01/202404/01/2023YYBUA 7018331432 B 5,000,000 25,000 Y Y 47-UMO-303445-09 04/01/2023 04/01/2024 5,000,000 WC7018331446CY 1,000,000No04/01/2023 04/01/2024 1,000,000 1,000,000 290839423917806SR ID:BATCH: Crown Castle Inc. Page 1 of 2 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: Crown Castle Inc. f/k/a Crown Castle International Corp.See Attached Named Insured List8020 Katy FreewayHouston, TX 77024 It is further agreed that such insurance as is afforded shall be Primary and Non-Contributory with any other insurancein force for or which may be purchased by Additional Insureds if agreed in written contract. Automobile Liability is Primary and Non-Contributory for owned autos. The Umbrella Liability policy shall be Primary and Non-Contributory with any other insurance in force for or which maybe purchased by Additional Insureds if agreed in written contract. General Liability, Automobile Liability, Umbrella/Excess Liability, and Workers Compensation includes a Waiver ofSubrogation in favor of the certificate holder when agreed in written contract prior to the loss, but always subjectto the policy terms, conditions and exclusions as permitted by law. 2 2 Willis Towers Watson Northeast, Inc. See Page 1 See Page 1 See Page 1 See Page 1 25 Certificate of Liability Insurance W28461342CERT:2908394BATCH:23917806SR ID: Crown Castle Inc. Edition Date: 12/22 Named Insured Named Insured (cont.) AirComm of Avon, LLC Crown Castle Puerto Rico Corp. Assurable Insurance LLC Crown Castle Solutions LLC Atlantic Coast Communications LLC Crown Castle South LLC CC Edge LLC Crown Castle Towers 05 LLC CC Holdings GS V LLC Crown Castle Towers 06-2 LLC CC Site Acquisitions II LLC Crown Castle Towers 09 LLC CC Strategic Investments Corp.Crown Castle Towers LLC CC TM PA LLC Crown Castle USA Inc. CC Towers Guarantor LLC Crown Communication LLC CC Towers Holding LLC Crown Communication New York, Inc. CCATT Holdings LLC Fibertech Facilities Corp. CCATT LLC Global Signal Acquisitions II LLC CCATT PR LLC Global Signal Acquisitions III LLC CCGS Holdings Corp. Global Signal Acquisitions IV LLC CCPR VI Tower Newco LLC Global Signal Acquisitions LLC CCS & E LLC Global Signal GP LLC CCTM Holdings LLC Global Signal Holdings III LLC CCTM1 LLC Global Signal Operating Partnership, LP CCTM2 LLC GoldenState Towers LLC CCTMO LLC GS Savings Inc. CCVX LLC GSPN Intangibles LLC ComSite Venture, Inc.High Point Management Co. LLC Coverage Plus Antennas Systems LLC ICB Towers LLC Crown Atlantic Company LLC Interstate Tower Communications LLC Crown Castle AS LLC Intracoastal City Towers LLC Crown Castle Atlantic LLC Light Tower Clearinghouse LLC Crown Castle CA Corp. Md7 Capitol One, LLC Crown Castle Fiber Enterprise LLC MW Cell Reit 1 LLC Crown Castle Fiber Holdings Corp.MW Cell TRS 1 LLC Crown Castle Fiber LLC OP LLC Crown Castle GS III Corp.OP 2 LLC Crown Castle GT Company LLC Pinnacle Towers Acquisition Holdings LLC Crown Castle GT Corp.Pinnacle Towers Acquisition LLC Crown Castle GT Holding Sub LLC Pinnacle Towers Asset Holding LLC Crown Castle Inc.Pinnacle Towers Canada Inc. Crown Castle LLC Pinnacle Towers III LLC Crown Castle Investment Corp.Pinnacle Towers Limited Crown Castle Investment II Corp.Pinnacle Towers LLC Crown Castle MU LLC Pinnacle Towers V Inc. Crown Castle MUPA LLC PR Site Development Corporation Crown Castle NG East LLC Radio Station WGLD LLC Crown Castle Operating Company Shaffer & Associates, Inc. Crown Castle Operating LLC Sidera Networks UK Limited (UK) Crown Castle Orlando Corp.Sierra Towers, Inc. Crown Castle PR LLC Tower Development Corporation Crown Castle PR Solutions LLC Tower Systems LLC 1 of 2 Crown Castle Inc. Edition Date: 12/22 Named Insured Named Insured (cont.) Tower Technology Company of Jacksonville LLC Tower Ventures III LLC TowerOne Partners, LLC TriStar Investors LLC TVHT LLC WCP Wireless Lease Subsidiary, LLC WCP Wireless Site Funding LLC WCP Wireless Site Holdco LLC WCP Wireless Site Non-RE Funding LLC WCP Wireless Site Non-RE Holdco LLC WCP Wireless Site RE Funding LLC WCP Wireless Site RE Holdco LLC 2 of 2 Business Auto Policy Policy Endorsement NOTICE OF CANCELLATION TO CERTIFICATEHOLDERS It is understood and agreed that: If you have agreed under written contract to provide notice of cancellation to a party to whom the Agent of Record has issued a Certificate of Insurance, and if we cancel a policy term described on that Certificate of Insurance for any reason other than nonpayment of premium, then notice of cancellation will be provided to such Certificateholders at least 30 days in advance of the date cancellation is effective. If notice is mailed, then proof of mailing to the last known mailing address of the Certificateholder on file with the Agent of Record will be sufficient to prove notice. Any failure by us to notify such persons or organizations will not extend or invalidate such cancellation, or impose any liability or obligation upon us or the Agent of Record. All other terms and conditions of the policy remain unchanged This endorsement, which forms a part of and is for attachment to the policy issued by the designated Insurers, takes effect on the Policy Effective date of said policy at the hour stated in said policy, unless another effective date (the Endorsement Effective Date) is shown below, and expires concurrently with said policy. Endorsement No: 147; Page: 1 of 1 Underwriting Company: Continental Casualty Company, 151 N Franklin St, Chicago, IL 60606 Form No: CNA68021XX (02-2013) Endorsement Effective Date: Endorsement Expiration Date: © Copyright CNA All Rights Reserved. Policy No: BUA 7018331432 Policy Effective Date: 04/01/2023 Policy Page: 590 of 635 It is understood and agreed that: If you have agreed under written contract to provide notice of cancellation to a party to whom the Agent of Record has issued a Certificate of Insurance, and if we cancel a policy term described on that Certificate of Insurance for any reason other than nonpayment of premium, then notice of cancellation will be provided to such Certificate Holders at least 30 days in advance of the date cancellation is effective. If notice is mailed, then proof of mailing to the last known mailing address of the Certificate Holder on file with the Agent of Record will be sufficient to prove notice. Any failure by us to notify such persons or organizations will not extend or invalidate such cancellation, or impose any liability or obligation upon us or the Agent of Record. © CNA All Rights Reserved. Form No: CC68021A (02-2013) Page 1 of 1 Underwriting Company: Continental Casualty Company NOTICE OF CANCELLATION TO CERTIFICATE HOLDERS Policy No: 7018331477 Policy Effective Date:4 /01/2023 Page 1  |  CLP‐UN‐067‐10/2013  ENDORSEMENT   This endorsement, effective 12:01AM:   Forms a part of Policy No.:   Issued to:      By:       NOTICE OF CANCELLATION - DESIGNATED ENTITIES OR INDIVIDUALS ENDORSEMENT THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.  This endorsement modifies insurance provided under the following:  COMMERCIAL GENERAL LIABILITY POLICY  COMMERCIAL UMBRELLA LIABILITY POLICY  COMMERCIAL RETAINED LIMIT LIABILITY INSURANCE POLICY  FOLLOW FORM EXCESS LIABILITY POLICY  PRODUCTS/COMPLETED OPERATIONS LIABILITY POLICY  The following is added to the policy:  SCHEDULE  Name and Address Notice of Cancellation  (Other Than Non‐Payment)  To be provided by Broker  2000 Corporate Drive  Canonsburg, PA 15317‐0000  30 days  Except with respect to cancellation for non‐payment of premium, the entities and individuals listed in the  Schedule of this endorsement shall receive prior written notice of cancellation not less than the number of days  listed for them in the Schedule, respectively.  Other than the right to receive notice of cancellation as set forth herein, however, this endorsement confers no  rights or status under this policy for any entity or individual listed in the Schedule of this endorsement.  All other terms and conditions of this policy remain unchanged.  04/01/2023 47-UMO-303445-09 Crown Castle Inc. Berkshire Hathaway Specialty Insurance Company Workers Compensation And Employers Liability Insurance Policyholder Notice NOTICE OF CANCELLATION TO CERTIFICATE HOLDERS It is understood and agreed that: If you have agreed under written contract to provide notice of cancellation to a party to whom the Agent of Record has issued a Certificate of Insurance, and if we cancel a policy term described on that Certificate of Insurance for any reason other than nonpayment of premium, then notice of cancellation will be provided to such Certificate Holders at least 30 days in advance of the date cancellation is effective. If notice is mailed, then proof of mailing to the last known mailing address of the Certificate Holder on file with the Agent of Record will be sufficient to prove notice. Any failure by us to notify such persons or organizations will not extend or invalidate such cancellation, or impose any liability or obligation upon us or the Agent of Record. All other terms and conditions of the policy remain unchanged. This endorsement, which forms a part of and is for attachment to the policy issued by the designated Insurers, takes effect on the Policy Effective Date of said policy at the hour stated in said policy, unless another effective date (the Endorsement Effective Date) is shown below, and expires concurrently with said policy unless another expiration date is shown below. Form No: Policy Effective Date: Underwriting Company: Policyholder Notice; Page: 1 of 1 The Continental Insurance Company, 151 N Franklin St, Chicago, IL 60606 CC68021A (02-2013) Policy Page: 4 of 382 © Copyright CNA All Rights Reserved. Policy No: WC 7018331446 04/01/2023