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HomeMy WebLinkAbout1 - Original Submission_ 20220720_4545_CONSOR Updated COI 12312022 EXPIRYANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? INSR ADDL SUBR LTR INSD WVD 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) 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 AGG $JECT OTHER:$ 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 LIMIT $DESCRIPTION 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. The ACORD name and logo are registered marks of ACORDACORD 25 (2016/03) CERTIFICATE OF LIABILITY INSURANCE Lockton Companies Three City Place Drive, Suite 900 St. Louis MO 63141-7081 (314) 432-0500 CONSOR North America, Inc. d.b.a. Murraysmith 888 SW 5th Ave, Suite 1170 Portland OR 97204-2025 *** SEE ATTACHMENT *** X X 1,000,000 500,000 10,000 1,000,000 2,000,000 2,000,000 X 1,000,000 XXXXXXX XXXXXXX XXXXXXX XS AutoLiab CSL 1,000,000 X X 10,000,000 10,000,000 XXXXXXX N X 1,000,000 1,000,000 1,000,000 Professional & Environmental Liability $10,000,000 per Claim $10,000,000 Aggregate Deductible: $150,000 A 84 UEN OL5490 (AOS)12/31/2021 12/31/2022A84 AB OL5683 (HI)12/31/2021 12/31/2022AP-001-000788084-01 (XS)12/31/2021 12/31/2022 A 6004-1073 12/31/2021 12/31/2022 A EBZ634816/01/2021 12/31/2021 12/31/2022 A TUE 3274463 02 12/31/2021 12/31/2022 A 0468405Y (AOS)12/31/2021 12/31/2022A0468405B (HI)12/31/2021 12/31/2022 12/31/2022 1407115 Y Y Y Y N N N 7/20/2022 N N 17378675 17378675 XXXXXXX City of Bremerton 345 6th Street, Suite 600 Bremerton WA 98337 THIS CERTIFICATE SUPERSEDES ALL PREVIOUSLY ISSUED CERTIFICATES FOR THIS HOLDER, APPLICABLE TO THE CARRIERS LISTED AND THE POLICY TERM(S) REFERENCED. MS Project #19-2576/ Pump Station 14 R See Attachments DocuSign Envelope ID: C620D2C2-9FD6-4A11-89FD-D1495F28627E CONTINUATION DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS (Use only if more space is required) ACORD 25 (2016/03) The City of Bremerton is included as additional insured on a Primary and Non-contributory basis if required by written contract with respect to General Liability and Automobile Liability per the terms and conditions of the policy. A waiver of subrogation applies in favor of The City of Bremerton if required by written contract with respect to General Liability and Automobile Liability per the terms and conditions of the policy where permitted by state law. Certificate Holder ID: 17378675 DocuSign Envelope ID: C620D2C2-9FD6-4A11-89FD-D1495F28627E Insurers Allied World Insurance Company (NAIC # 22730) – 6004-1073 Hartford Fire Insurance Company (NAIC # 19682) – 84 UEN OL5490 (AOS) Hartford Underwriters Insurance Company (NAIC # 30104) – 84 AB OL5683 (HI) AXIS Surplus Insurance Company (NAIC # 26620) – P-001-000788084-01 (XS Layer) Great American Insurance Company (NAIC # 16691) – TUE 3274463 02 Manufacturers Alliance Insurance Company (NAIC # 36897) – 0468405Y (AOS) Pennsylvania Manufacturers Association (NAIC # 12262) – 0468405B (HI) AXIS Surplus Insurance Company (NAIC # 26620) - EBZ634816/01/2021 Aspen American Insurance Company (NAIC # 43460) – OM00PUX21 Federal Insurance Company (NAIC # 20281) – 8250-1945 Miscellaneous Attachment: M602380 Master ID: 1407115, Certificate ID: 17378675 DocuSign Envelope ID: C620D2C2-9FD6-4A11-89FD-D1495F28627E City of Bremerton 345 6th Street, Suite 600 Lockton Companies Three CityPlace Dr, Suite 900 / St. Louis, MO 63141-7088 314-432-0500 / lockton.com Bremerton WA 98337 To whom it may concern: In our continuing effort to provide timely certificate delivery, Lockton Companies is transitioning to paperless delivery of Certificates of Insurance. To ensure electronic delivery for future renewals of this certificate, we need your email address. Please contact us via one of the methods below, referencing Certificate ID 17378675. • Email: STL-edelivery@lockton.com • Phone: (866) 728-5657 (toll-free) If you received this certificate through an internet link where the current certificate is viewable, we have your email and no further action is needed. In the event your mailing address has changed, will change in the future, or you no longer require this certificate, please let us know using one of the methods above. The above inbox is for providing e-Delivery email addresses for next year’s renewal certificates ONLY. Your information will be input within 90 days. Thank you for your cooperation and willingness in reducing our environmental footprint. Lockton Companies Attachment Code: D545910 Master ID: 1407115, Certificate ID: 17378675 DocuSign Envelope ID: C620D2C2-9FD6-4A11-89FD-D1495F28627E