Loading...
HomeMy WebLinkAboutCity of Bremerton_PetroCard, Inc._25-26 GAEW + 2nd XS PollProf_3-17-2025_664781399SHOULD 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 3/17/2025 Marsh &McLennan Agency LLC1031W4thAve,Suite 400AnchorageAK99501 Jamie Esquivel 907-276-5617 jamie.esquivel@marshmma.com License#:82353 Evanston Insurance Company 35378 BRISTBAY10 Zurich American Insurance Company 16535PetroCard,Inc.730 S Central AvenueKent,WA 98032-0000 Navigators Specialty Insurance Company 36056 American Zurich Insurance Company 40142 664781399 A X 1,000,000 X 300,000 10,000 1,000,000 2,000,000 X Y Y MKLV5ENV105077 4/1/2025 4/1/2026 2,000,000 B 1,000,000 X Y Y BAP927545024 4/1/2025 4/1/2026 CA X 10,000,000 X Y LA25EXC725167ICMKLV5EUE103952 4/1/20254/1/2025 N 4/1/20264/1/2026 10,000,000 DB X N Y WC588844820WC488669015 4/1/20254/1/2025 4/1/20264/1/2026 1,000,000 1,000,000 1,000,000 A PollutionLiability /ProfessionalLiability N N MKLV5ENV105076 4/1/2025 4/1/2026 Per Claim LimitAggregateLimit $10,000,000$10,000,000 Re:Evidence of Insurance.Subject to said policy limits,terms,and exclusions.Where required by written contract,Certificate Holder is an Additional Insured ontheGeneralLiabilityandAutoLiabilitypolicies,subject to the terms,conditions and limitations of said policies and the additional insured endorsement.Whererequiredbywrittencontract,Waiver of Subrogation in favor of Certificate Holder applies to referenced policies subject to the terms,conditions and limitations ofsaidpoliciesandtheWaiverofSubrogationendorsement.It is further agreed that,where required by written contract,the General Liability and Auto LiabilityinsuranceasisaffordedtheCertificateHoldershallbeprimaryandnoncontributorywithanyotherinsuranceinforcefororwhichmaybepurchasedbytheCertificateHolder. City of BremertonFinancialServices345SixthStreetSuite600BremertonWA98337-1873 ADDITIONAL REMARKS SCHEDULE Page of AGENCY NAMED INSURED CARRIER NAIC CODE EFFECTIVE DATE: ADDITIONAL REMARKS THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, FORM NUMBER: FORM TITLE: ACORD 101 (2008/01) © 2008 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD This is evidence of insurance procured and developed under the Alaska Surplus Lines Law, AS 21.34. It is not covered by the Alaska Insurance Guaranty Association Act, AS 21.80. Certificate of Liability25 PetroCard,Inc.Marsh &McLennan Agency LLC