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HomeMy WebLinkAboutCTL Tresting COI 04-01-23 to 04-01-24INSR ADDLSUBRLTRINSRWVD DATE (MM/DD/YYYY) 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) COMMERCIAL GENERAL LIABILITY 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 INSURER(S) AFFORDING COVERAGE NAIC # Y / N N / A (Mandatory in NH) ANY PROPRIETOR/PARTNER/EXECUTIVEOFFICER/MEMBER EXCLUDED? EACH OCCURRENCE $ DAMAGE TO RENTED $PREMISES (Ea occurrence)CLAIMS-MADE OCCUR MED EXP (Any one person)$ PERSONAL & ADV INJURY $ GENERAL AGGREGATE $GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP/OP AGG $ $ PRO- OTHER: LOCJECT COMBINED SINGLE LIMIT $(Ea accident) BODILY INJURY (Per person)$ANY AUTO OWNED SCHEDULED BODILY INJURY (Per accident)$AUTOS ONLY AUTOS AUTOS ONLYHIRED PROPERTY DAMAGE $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 LIMIT $DESCRIPTION OF OPERATIONS below POLICY NON-OWNED 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 any 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. The ACORD name and logo are registered marks of ACORDACORD 25 (2016/03) ACORDTM CERTIFICATE OF LIABILITY INSURANCE Alaska National Insurance Company SiriusPoint Specialty Insurance Corp 3/31/2023 Propel Insurance 1201 Pacific Avenue; Suite 1000 COM Construction Tacoma, WA 98402-4321 Sharnel Di Vona 800 499-0933 866 577-1326 sharnel.divona@propelinsurance.com Construction Testing Laboratories, Inc 400 Valley Ave NE Puyallup, WA 98372 38733 16820 A X X X PD Ded: 1,000 X WA stop Gap X X 23DLS11734 04/01/2023 04/01/2024 1,000,000 100,000 5,000 1,000,000 2,000,000 2,000,000 1,000,000Stop Gap A X X X 23DAT11734 04/01/2023 04/01/2024 1,000,000 A X X X 10000 23DLU11734 04/01/2023 04/01/2024 5,000,000 5,000,000 A N WA Stop Gap Only 23DLS11734 04/01/2023 04/01/2024 Y $1,000,000 $1,000,000 $1,000,000 B Pollution w/mold CPPLS00022120 04/01/2023 04/01/2024 $3,000,000 limit $25,000 ded. RE: City of Bremerton Pump Station 14 Relocation Project. Additional Insured Status applies per attached form(s). Waiver of Subrogation applies per attached form(s). Prospect Construction Inc 116 23rd Street SE Edgewood, WA 98372 1 of 1 #S5785002/M5784800 MILESANDClient#: 17793 KTR00 1 of 1 #S5785002/M5784800 This page has been left blank intentionally. Alaska National INSURANCE COMPANY b.If a claim is made or "suit" is brought against the additional insured, the additional insured must: (1)Immediately record the specifics of the claim or "suit" and the date received; and (2)Notify us as soon as practicable. The additional insured must see to it that we receive written notice of the claim or "suit" as soon as practicable. c.The additional insured must immediately send us copies of all legal papers received in connection with the claim or "suit", cooperate with us in the investigation or settlement of the claim or defense against the "suit", and otherwise comply with all policy conditions. d.The additional insured must tender the defense and indemnity of any claim or "suit" to any provider of other insurance which would cover the additional insured for a loss we cover under this endorsement. However, this condition does not affect whether the insurance provided to the additional insured by this endorsement is primary to other insurance available to the additional insured which covers that person or organization as a named insured as described in Paragraph 3. above. 6.The following is added to the DEFINITIONS Section: "Written contract requiring insurance" means that part of any written contract or agreement for construction services under which you are required to include a person or organization as an additional insured on this Coverage Part, provided that the "bodily injury" and "property damage" occurs, and the "personal and advertising injury" is caused by an offense committed, during the policy period and: a.After the signing and execution of the contract or agreement by you; and b.While that part of the contract or agreement is in effect. This endorsement changes the policy to which it is attached and, unless otherwise stated, is effective on the date issued at 12:01 AM. standard time at your mailing address shown in the policy. The information below is required only when this endorsement is issued subsequent to commencement of the policy. Policy No. 22D LS 11734 Endorsement Effective 4-1-2022 Insured Miles Sand & Gravel Endorsement No. Countersigned By ------------------- Includes copyrighted material of the Insurance Services Office, Inc., with its permission. ANIC GL 1218 05 18 Page 3 of 3 This page has been left blank intentionally. ANIC GL 1187 08 21 Page 1 of 7 CONTRACTORS’ GENERAL LIABILITY ENHANCEMENT ENDORSEMENT THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART Coverage afforded under this extension of coverage endorsement does not apply to any person or organization covered as an additional insured on any other endorsement now or hereafter attached to this Coverage Part. SCHEDULE OF COVERAGES ARE SUMMARIZED BELOW 1. Miscellaneous Additional Insureds 8 additional insured extensions. Primary and Noncontributory Insurance 2. Damage To Premises Rented to You Limit increased to $500,000. 3. Medical Payments Limits increased to $15,000. Reporting period increased to three years from the date of accident. 4. Non-owned Watercraft Increased to 50 feet. 5. Supplementary Payments Cost of bail bonds increased to $10,000. Daily loss of earnings increased to $500. 6. Newly Formed Or Acquired Organizations Coverage extended to the end of the policy period or the next anniversary of this policy’s effective date. 7. Liberalization Clause 8. Unintentional Failure To Disclose Hazards 9. Notice of Occurrence 10. Broad Knowledge of Occurrence 11. Bodily Injury - Extension of Coverage 12. Expected Or Intended Injury Reasonable force - bodily injury or property damage. 13. Blanket Waiver of Subrogation Waiver of subrogation where required by written contract or written agreement. 14. In Rem Actions 15. Voluntary Property Damage Limits added: $5,000 occurrence, $10,000 aggregate. 1. MISCELLANEOUS ADDITIONAL INSUREDS Section II Who Is An Insured is amended to include as an additional Insured any person or organization described in Paragraphs 2.a. through 2.h. below whom you are required to add as an additional insured on this policy under a written contract or written agreement. However, the written contract or written agreement must be: 1. Currently in effect or becoming effective during the term of this policy; and 2. Executed prior to the “bodily injury”, “property damage” or “personal injury and advertising injury”, but Only the following persons or organizations are additional insureds under this endorsement and coverage provided to such additional insureds is limited as provided herein: a. State or Governmental Agency or Subdivision or Political Subdivi- sions ANIC GL 1187 08 21 Page 2 of 7 Any state or governmental agency or subdivision or political subdivision that has issued a permit in connection with operations performed by you or on your behalf and that you are required by any ordinance, law or building code to include as an additional insured on this coverage part is an additional insured, but only with respect to liability for “bodily injury”, “property damage”, “personal and advertising injury” arising out of such operations. The insurance provided to such state or political subdivision does not apply to any “bodily injury”, “property damage” or “personal and advertising injury” arising out of operations performed for that state or political subdivision. b. Controlling Interest Any persons or organizations with a controlling interest in you but only with respect to their liability arising out of: (1) Their financial control of you, or (2) Premises they own, maintain or control while you lease or occupy these premises. This insurance does not apply to structural alterations, new construc- tion and demolition operations performed by or for such additional insured. c. Managers or Lessors of Premises A manager or lessor of premises but only with respect to liability arising out of the ownership, maintenance or use of that specific part of the premises leased to you and subject to the following additional exclusions: This insurance does not apply to: (1) Any “occurrence” which takes place after you cease to be a tenant in that premises; or (2) Structural alterations, new con- struction or demolition operations performed by or on behalf of such additional insured. d. Mortgagee, Assignee or Receiver A mortgagee, assignee or receiver but only with respect to their liability as mortgagee, assignee, or receiver and arising out of the ownership, maintenance, or use of a premises by you. This insurance does not apply to structural alterations, new construc- tion or demolition operations performed by or for such additional insured. e. Owners or Other Interests From Whom Land Has Been Leased An owner or other interest from whom land has been leased by you but only with respect to liability arising out of the ownership, maintenance or use of that specific part of the land leased to you and subject to the following additional exclusions: This insurance does not apply to: (1) Any “occurrence” which takes place after you cease to lease that land; or (2) Structural alterations, new con- struction or demolition operations performed by or on behalf of such additional insured. f. Co-owner of Insured Premises A co-owner of a premises co-owned by you and covered under this insurance but only with respect to the co-owners liability as co-owner of such premises. ANIC GL 1187 08 21 Page 3 of 7 g. Lessor of Equipment Any person or organization from whom you lease equipment. Such person or organization is an additional insured only with respect to their liability for “bodily injury”, “property damage” or “personal and Advertising injury” caused, in whole or in part, by your maintenance, oper- ation or use of equipment leased to you by such person or organization. A person’s or organization’s status as an additional insured under this endorsement ends when their written contract or written agreement with you for such leased equipment ends. With respect to the insurance afforded these additional insureds, the following additional exclusions apply: This insurance does not apply: (1) To any “occurrence” which takes place after the equipment lease expires; or (2) To “bodily injury”, “property damage”, or “personal and advertising injury” arising out of the sole negligence of such additional insured. h. Owners, Lessees or Contractors – Ongoing Operations and Completed Operations 1. Any person or organization for whom you are performing operations or have performed operations when you and such person or organization have agreed in writing in a contract or agreement that such person or organization be added as an additional insured on your policy; and 2. Any other person or organization you are required to add as an additional insured under the contract or agreement described in Paragraph 1. above. Such person(s) or organization(s) is an additional insured only with respect to liability for “bodily injury”, “property damage” or “personal and advertising injury” caused, in whole or in part, by: a. Your acts or omissions; or b. The acts or omissions of those acting on your behalf; or c. “Your Work” performed for the additional insured described in Paragraph 1. or 2. above and included in the “products-completed operations hazard.” In the performance of your ongoing operations or completed operations for the additional insured described in Paragraph 1. or 2. above. However, the insurance afforded to such additional insured described above: a. Only applies to the extent permitted by law; and b. Will not be broader than that which you are required by the contract or agreement to provide for such additional insured. 3. With respect to the insurance afforded to these additional insureds, the following additional exclusions apply: This insurance does not apply to: 1. “Bodily injury”, “property damage” or “personal and advertising injury” arising out of the rendering of, or the failure to render, any professional architectural, engineering or surveying services, including: ANIC GL 1187 08 21 Page 4 of 7 a. The preparing, approving, or failing to prepare or approve, maps, shop drawings, opinions, reports, surveys, field orders, change orders or drawings and specifica- tions; or b. Supervisory, inspection, architectural or engineering activities. This exclusion applies even if the claims against any insured allege negligence or other wrongdoing in the supervision, hiring, employ- ment, training or monitoring of others by that insured, if the “occurrence” which caused the “bodily injury” or “property damage”, or the offense which caused the “personal and advertising injury”, involved the rendering of, or the failure to render, any professional architectural, engineering or surveying services. Primary And Noncontributory Insurance The following is added to the Other Insurance Condition and supersedes any provision to the contrary: This insurance is primary to and will not seek contribution from any other insurance available to an additional insured under your policy provided that: (1) The additional insured is a Named Insured under such other insurance; and (2) You have agreed in writing in a contract or agreement that this insurance would be primary and would not seek contribution from any other insurance available to the additional insured. Section III - Limits of Insurance, the following is added: With respect to the insurance afforded to the additional insureds described in Paragraphs a. through h. above, the most we will pay on behalf of such additional insured is the amount of insurance: (1) Required by the contract or agreement; or (2) Available under the applicable Limits of Insurance shown in the Declarations; whichever is less. This provision shall not increase the applicable Limits of Insurance shown in the Declaration. 2. Damage To Premises Rented to You SECTION III – LIMITS OF INSURANCE, Paragraph 6. is replaced by the following: 6. Subject to Paragraph 5. above, the Damage to Premises Rented to You Limit is the most we will pay under Coverage A for damages because of “property damage” to any one premises, while rented to you, or in the case of damage by fire, while rented to you or temporarily occupied by you with permission of the owner. If a limit is shown for Damage to Premises Rented to You the most we will pay under Coverage A for damages because or “property damage” to any one premises is the Limit shown in the Declarations or $500,000, whichever is greater. 3. MEDICAL PAYMENTS A. Section lll – Limits of Insurance, Paragraph 7. is replaced by the following: 7. Subject to Paragraph 5. above the Medical Expense Limit is the most we will pay under Coverage C for all medical expenses because of “bodily injury” sustained by any one person. ANIC GL 1187 08 21 Page 5 of 7 If a limit is shown for Medical Expense in the Declarations the most we will pay under Coverage C for all medical expenses because of “bodily injury” sustained by any one person is the Limit shown in the Declarations or $15,000, whichever is greater. B. This provision 5. (Medical Payments) does not apply if Section I - Coverage C Medical Payments is excluded either by the provisions of the Coverage Part or by endorsement. C. Paragraph 1.a.(3)(b) of Section I - Coverage C - Medical Payments, is replaced by the following: (b) The expenses are incurred and reported to us within three years of the date of the accident; and 4. NON-OWNED WATERCRAFT A. If endorsement CG 21 09, CG 21 10, CG 24 50, or CG 24 51 is attached to the policy, Paragraph A. 2. g. (2) (b) is replaced by the following: (b) A watercraft that you do not own that is: (i) Less than 50 feet long: and (ii) Not being used to carry persons or property for a charge. B. If Paragraph A. does not apply, Paragraph g. (2) of 2. EXCLUSION under SECTION l – COVERAGES, COVERAGE A – BODILY INJURY AND PROPERTY DAMAGE LIABILITY is replaced by the following: (2) A watercraft that you do not own that is: (a) Less than 50 feet long; and (b) Not being used to carry persons or property for a charge. 5. SUPPLEMENTARY PAYMENTS A. Under Section I - Supplementary Payments - Coverage A and B, Paragraph 1.b., the limit of $250 shown for the cost of bail bonds is replaced by $10,000; B. In Paragraph 1.d., the limit of $250 shown for daily loss of earnings is replaced by $500. 6. NEWLY FORMED OR ACQUIRED ORGANIZATIONS Paragraph 3.a. of Section II - Who Is An Insured is deleted and replaced by the following: Coverage under this provision is afforded only until the end of the policy period or the next anniversary of this policy’s effective date after you acquire or form the organization, whichever is earlier. 7. LIBERALIZATION CLAUSE If we adopt a change in our forms or rules which would broaden coverage for contractors under this endorsement without an additional premium charge, your policy will automatically provide the additional coverages as of the date the revision is effective in your state. 8. UNINTENTIONAL FAILURE TO DISCLOSE HAZARDS SECTION IV – COMMERCIAL GENERAL LIABILITY CONDITIONS – Paragraph 6. – Representations is replaced by the following: 6. Representations By accepting this policy, you agree: a. The statements in the Declarations are accurate and complete; b. Those statements are based upon representations you made to us; and c. We have issued this policy in reliance upon your representations. ANIC GL 1187 08 21 Page 6 of 7 The unintentional omission of, or unintentional error in, any information you provided to us which we relied upon in issuing this policy will not prejudice your rights under this insurance. However, this provision does not affect our right to collect additional premium or to exercise our rights of cancellation or nonrenewal in accordance with applicable laws and regulations. 9. NOTICE OF OCCURRENCE The following is added to Paragraph 2. of Section IV - Commercial General Liability Conditions - Duties In The Event of Occurrence, Offense, Claim or Suit: Your rights under this Coverage Part will not be prejudiced if you fail to give us notice of an “occurrence”, offense, claim or “suit” and that failure is solely due to your reasonable belief that the “bodily injury” or “property damage” is not covered under this Coverage Part. However, you shall give written notice of this “occurrence”, offense, claim or “suit” to us as soon as you are aware that this insurance may apply to such “occurrence”, offense, claim or “suit.” 10. BROAD KNOWLEDGE OF OCCURRENCE The following is added to Paragraph 2. of Section IV - Commercial General Liability Conditions - Duties in The Event of Occurrence, Offense, Claim or Suit: You must give us or our authorized representative notice of an “occurrence”, offense, claim, or “suit” only when the “occurrence”, offense, claim or “suit’ is known to: (1) You, if you are an individual; (2) A partner, if you are a partnership; (3) An executive officer or the employee designated by you to give such notice, if you are a corporation; or (4) A manager, if you are a limited liability company. 11. EXPANDED BODILY INJURY Section V - Definitions, the definition of “bodily injury” is changed to read: “Bodily injury” means bodily injury, sickness or disease sustained by a person, including death, humiliation, shock, mental anguish or mental injury by that person at any time which results as a consequence of the bodily injury, sickness or disease. 12. EXPECTED OR INTENDED INJURY Exclusion a. of Section I - Coverage A - Bodily Injury and Property Damage Liability is replaced by the following: a. “Bodily injury” or “property damage” expected or intended from the standpoint of the insured. This exclusion does not apply to “bodily injury” or “property damage” resulting from the use of reasonable force to protect persons or property. 13. BLANKET WAIVER OF SUBROGATION The Transfer Of Rights Of Recovery Against Others To Us Condition (Section IV - Commercial General Liability Conditions) is amended by the addition of the following: We waive any right of recovery against any person or organization, because of any payment we make under this Coverage Part, to whom the insured has waived its right of recovery in a written contract or agreement. Such waiver by us applies only to the extent that the insured has waived its right of recovery against such person or organization prior to loss. Includes copyrighted material of Insurance Services Office, Inc., with its permission ANIC GL 1187 08 21 Page 7 of 7 14. IN REM ACTIONS Any action in rem against any vessel owned, operated by or for, or chartered by or for you will be treated in the same manner as though the action were in personam against you. 15. VOLUNTARY PROPERTY DAMAGE The following is added, Section I – Coverage A – Bodily Injury and Property Damage Liability 1., Insuring Agreement: We will pay, at your request, for “property damage” to property of others while in the care, custody or control of an insured, arising out of your business operations away from your insured premises for which this policy is written and occurring during the policy period. However, the “property damage” must be the result of unintentional damage or destruction but does not include disappearance, theft, or loss of use. You agree with us that we shall have no duty to defend any claims and/or “suits” for which t he only coverage provided is under this coverage extension. For the purpose of this coverage only, Section I – Coverage A – Bodily Injury and Property Damage Liability 2. Exclusions J. (4.) is deleted. As respects coverage afforded under Voluntary Property Damage, the following is added to Section III – Limits of Insurance: Regardless of the number of insureds, claims or “suits” brought, or persons or organizations making claims or bringing “suits”: 1. Subject to 2. Below, the most we will pay for “property damage” arising from any one “occurrence” arising out of “property damage to property of others caused by you and while in your care, custody or control is $5,000. 2. The most we will pay for the sum of all “property damage” in an annual policy period is $10,000. This amount is part of and not in addition to the General Aggregate Limit described in Paragraph 2. of Section III – Limits of Insurance. This page has been left blank intentionally. This page has been left blank intentionally. This endorsement changes the policy to which it is attached and, unless otherwise stated, is effective on the date issued at 12:01 A.M. standard time at your mailing address shown in the policy. The information below is required only when this endorsement is issued subsequent to commencement of the policy. Endorsement Effective Policy No. Insured Endorsement No. Countersigned By Includes copyrighted material of Insurance Services Office, Inc., with its permission ANIC CU 1149 11 15 ADDITIONAL INSUREDS PRIMARY AND NON-CONTRIBUTORY THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. This endorsement modifies insurance provided under the following: COMMERCIAL LIABILITY UMBRELLA COVERAGE PART Paragraph a. of 5. Other Insurance of Section IV - Conditions is deleted and replaced by: 5. Other Insurance a. This insurance is excess over, and shall not contribute with any of the other insurance, whether primary, excess, contingent or on any other basis. This condition will not apply to either: (1) Other insurance that is specifically written as excess over this Coverage Part; or (2) Other insurance that is both: (a) Issued to a Named Insured that is an additional insured under this Coverage Part as described in paragraph 3. of Section II - Who Is An Insured; and (b) Intended to be excess of this insurance and non-contributory with this insurance as agreed under a written contract or agreement into which you have entered that requires that this insurance be primary and non-contributory. Such insurance as is described in items (1) and (2) above shall apply in excess of the Limits of Insurance of this Coverage Part and we will not seek contribution or indemnity from such insurance for damages to which this Coverage Part applies. When this insurance is excess, we will have no duty under Coverages A or B to defend the insured against any “suit” if any other insurer has a duty to defend the insured against that “suit”. If no other insurer defends, we will undertake to do so, but will be entitled to the insured’s rights against all those other insurers. 4 This page has been left blank intentionally.