Loading...
HomeMy WebLinkAbout21154 COI CGL 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 National Union Fire Ins Co of Pittsburg 3/22/2023 Edgewood Partners Ins. Center 3780 Mansell Rd. Suite 370 Alpharetta, GA 30022 Sharon Brubaker 770.756.6599 greylingcerts@greyling.com KPG Psomas Inc. 3131 Elliott Avenue, Suite 400 Seattle, WA 98121 19445 23-24 A X X X GL5268212 04/01/2023 04/01/2024 1000,000 500,000 25,000 1,000,000 2.000,000 2,000,000 A X X X CA4489706 04/01/2023 04/01/2024 2,000,000 A A N WC015893764 (AOS) WC015893765 (CA) 04/01/2023 04/01/2023 04/01/2024 04/01/2024 X 1,000,000 1,000,000 1,000,000 KPG PN 21154 - West Kitsap Way Planning Study. City of Bremerton is named as an Additional Insured on the above referenced liability policies with the exception of workers compensation where required by written contract. The above referenced liability policies with the exception of workers compensation and professional liability are primary & non-contributory where required by written contract. (See Attached Descriptions) City of Bremerton ATTN: Noreen Bolo 345 6th Street Suite 100; Bremerton, WA 98337-0000 1 of 2 #S5373634/M5371447 PSOMASClient#: 247197 SBR08 SAGITTA 25.3 (2016/03) DESCRIPTIONS (Continued from Page 1) Waiver of Subrogation is applicable where required by written contract & allowed by law. Should any of the above described policies be cancelled by the issuing insurer before the expiration date thereof, 30 days' written notice (except 10 days for nonpayment of premium) will be provided to the Certificate Holder. 2 of 2 #S5373634/M5371447 ENDORSEMENT This endorsement, effective 12:01 A.M.  forms a part of policy No. CA 454-49-27 by National Union Fire Insurance Company of Pittsburgh, PA THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - WHERE REQUIRED UNDER CONTRACT OR AGREEMENT This endorsement modifies insurance provided under the following: BUSINESS AUTO COVERAGE FORM SCHEDULE ADDITIONAL INSURED: ANY PERSON OR ORGANIZATION FOR WHOM YOU ARE CONTRACTUALLY BOUND TO PROVIDE ADDITIONAL INSURED STATUS BUT ONLY TO THE EXTENT OF SUCH PERSON OR ORGANIZATIONS LIABILITY ARISING OUT OF THE USE OF A COVERED AUTO. I. SECTION II - LIABILITY COVERAGE, A. Coverage, 1. - Who Is Insured, is amended to add: d. Any person or organization, shown in the schedule above, to whom you become obligated to include as an additional insured under this policy, as a result of any contract or agreement you enter into which requires you to furnish insurance to that person or organization of the type provided by this policy, but only with respect to liability arising out of use of a covered "auto". However, the insurance provided will not exceed the lesser of: (1) The coverage and/or limits of this policy, or (2) The coverage and/or limits required by said contract or agreement. Authorized Representative or Countersignature (in States Where Applicable) 87950 (10/05) CA4489706 04/01/2023 This endorsement, effective12:01A.M.forms a part of policy No.issued to by This endorsement modifies insurance provided under the following: BUSINESS AUTO COVERAGE FORM All other terms and conditions remain unchanged. Authorized Representative or 74445 (10/99) Countersignature (in States WhereApplicable) THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. INSURANCE PRIMARY AS TO CERTAIN ADDITIONAL INSUREDS Section IV - Business Auto Conditions, B., General Conditions, 5., Other Insurance, c., is amended by the addition of the following sentence: The insurance afforded under this policy to an additional insured will apply as primary insurance for such additional insured where so required under an agreement executed prior to the date of accident. We will not ask any insurer that has issued other insurance to such additional insured to contribute to the settlement of loss arising out of such accident. ENDORSEMENT ENSAFE INC. NATIONAL UNION FIRE INSURANCE COMPANY OF PITTSBURGH, PA CA4489706 KPG Psomas Inc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somas Inc. 04/01/2023 7KLVHQGRUVHPHQWHIIHFWLYH$0IRUPVDSDUWRI 3ROLF\1RLVVXHGWR %\ (1'256(0(17 /,0,7('$'9,&(2)&$1&(//$7,213529,'('9,$(0$,/   $XWKRUL]HG5HSUHVHQWDWLYH 3DJH 7+,6(1'256(0(17&+$1*(67+(32/,&<3/($6(5($',7&$5()8//< $OORWKHUWHUPVFRQGLWLRQVDQGH[FOXVLRQVVKDOOUHPDLQWKHVDPH 72(17,7,(627+(57+$17+(),5671$0(',1685(' ,QVXUHU 7KLVSROLF\LVDPHQGHGDVIROORZV ,QWKHHYHQWWKDWWKH,QVXUHUFDQFHOVWKLVSROLF\IRUDQ\UHDVRQRWKHUWKDQQRQSD\PHQWRISUHPLXP DQG  WKHFDQFHOODWLRQHIIHFWLYHGDWHLVSULRUWRWKLVSROLF\ VH[SLUDWLRQGDWH  WKH)LUVW1DPHG,QVXUHGLVXQGHUDQH[LVWLQJFRQWUDFWXDOREOLJDWLRQWRQRWLI\DFHUWLILFDWH KROGHU ZKHQWKLVSROLF\LV FDQFHOHG KHUHLQDIWHUWKH&HUWLILFDWH+ROGHU V   DQG KDV SURYLGHGWRWKH,QVXUHUHLWKHUGLUHFWO\RUWKURXJKLWVEURNHURIUHFRUGWKHHPDLODGGUHVV RIDFRQWDFWDWHDFKVXFKHQWLW\DQG  WKH,QVXUHUUHFHLYHGWKLVLQIRUPDWLRQDIWHUWKH)LUVW1DPHG,QVXUHGUHFHLYHVQRWLFHRI FDQFHOODWLRQRIWKLVSROLF\DQGSULRUWRWKLVSROLF\ VFDQFHOODWLRQHIIHFWLYHGDWHYLDDQ HOHFWURQLFVSUHDGVKHHWWKDWLVDFFHSWDEOHWRWKH WKH,QVXUHUZLOO SURYLGHDGYLFHRIFDQFHOODWLRQ WKH$GYLFH YLDHPDLOWRHDFKVXFK&HUWLILFDWH +ROGHUVZLWKLQGD\VDIWHUWKH)LUVW1DPHG,QVXUHGSURYLGHVVXFKLQIRUPDWLRQWRWKH,QVXUHUSURYLGHGKRZHYHUWKDWLIDVSHFLILFQXPEHURIGD\VLVQRWVWDWHGDERYHWKHQWKH$GYLFHZLOOEH SURYLGHG WR VXFK&HUWLILFDWH+ROGHU V  DV VRRQ DV UHDVRQDEO\SUDFWLFDEOHDIWHU WKH)LUVW 1DPHG ,QVXUHGSURYLGHVVXFKLQIRUPDWLRQWRWKH,QVXUHU 3URRIRIWKH,QVXUHUHPDLOLQJWKH$GYLFHXVLQJWKHLQIRUPDWLRQSURYLGHGE\WKH)LUVW1DPHG,QVXUHG ZLOOVHUYHDVSURRIWKDWWKH,QVXUHUKDVIXOO\VDWLVILHGLWVREOLJDWLRQVXQGHUWKLVHQGRUVHPHQW 7KLV HQGRUVHPHQW GRHV QRW DIIHFW LQ DQ\ ZD\ FRYHUDJH SURYLGHG XQGHU WKLV SROLF\ RU WKHFDQFHOODWLRQRIWKLVSROLF\RUWKHHIIHFWLYHGDWHWKHUHRIQRUVKDOOWKLVHQGRUVHPHQWLQYHVWDQ\ULJKWV LQDQ\HQWLW\QRWLQVXUHGXQGHUWKLVSROLF\ 7KHIROORZLQJ'HILQLWLRQVDSSO\WRWKLVHQGRUVHPHQW )LUVW 1DPHG,QVXUHG PHDQVWKH1DPHG,QVXUHGVKRZQ RQWKH'HFODUDWLRQV3DJHRIWKLV SROLF\ ,QVXUHUPHDQVWKHLQVXUDQFHFRPSDQ\VKRZQLQWKHKHDGHURQWKH'HFODUDWLRQVSDJHRIWKLV SROLF\  */ 35,086%8,/'(56,1& 1$7,21$/81,21),5(,1685$1&(&203$1<2)3,776%85*+3$ GL5268212 04/01/2023 KPG Psomas Inc. POLICY NUMBER: ADDITIONAL INSURED - OWNERS, LESSEES ORCONTRACTORS - SCHEDULED PERSON OR ORGANIZATION This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Name Of Additional Insured Person(s) Or Organization(s)Location(s) Of Covered Operations COMMERCIAL GENERAL LIABILITY CG 20 10 12 19 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. Information required to complete this Schedule, if not shown above, will be shown in the Declarations. Insurance Services Office, Inc., 2018CG 20 10 12 19 Page 1 of 2 A. Section II 6 Who Is An Insured is amended to include as an additional insured the person(s) or organization(s) shown in the Schedule, but only with respect to liability for "bodily injury", "property damage" or "personal and advertising injury" caused, in whole or in part, by: 1.Your acts or omissions; or 2.The acts or omissions of those acting on your behalf; in the performance of your ongoing operations for the additional insured(s) at the location(s) designated above. However: 1.The insurance afforded to such additional insured only applies to the extent permitted by law; and 2.If coverage provided to the additional insured is required by a contract or agreement, the insurance afforded to such additional insured will not be broader than that which you are required by the contract or agreement to provide for such additional insured. B.With respect to the insurance afforded to these additional insureds, the following additional exclusions apply: This insurance does not apply to "bodily injury" or "property damage" occurring after: 1.All work, including materials, parts or equipment furnished in connection with such work, on the project (other than service, maintenance or repairs) to be performed by or on behalf of the additional insured(s) at the location of the covered operations has been completed; or 2.That portion of "your work" out of which the injury or damage arises has been put to its intended use by any person or organization other than another contractor or subcontractor engaged in performing operations for a principal as a part of the same project. ANY PERSON OR ORGANIZATION WHOM YOU BECOME OBLIGATED TO INCLUDE AS AN PER THE CONTRACT OR AGREEMENT. ADDITIONAL INSURED AS A RESULT OF ANY CONTRACT OR AGREEMENT YOU HAVE ENTERED INTO. GL5268212 Insurance Services Office, Inc., 2018Page 2 of 2 CG 20 10 12 19 C.With respect to the insurance afforded to these additional insureds, the following is added to Section III – Limits Of Insurance: If coverage provided to the additional insured is required by a contract or agreement, the most we will pay on behalf of the additional insured is the amount of insurance: 1.Required by the contract or agreement; or 2.Available under the applicable limits of insurance; whichever is less. This endorsement shall not increase the applicable limits of insurance. POLICY NUMBER: ADDITIONAL INSURED - OWNERS, LESSEES OR CONTRACTORS - COMPLETED OPERATIONS This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Name Of Additional Insured Person(s) Or Organization(s)Location And Description Of Completed Operations COMMERCIAL GENERAL LIABILITY CG 20 37 12 19 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE PART ANY PERSON OR ORGANIZATION WHOM YOU BECOME OBLIGATED TO INCLUDE AS AN ADDITIONAL INSURED AS A RESULT OF ANY CONTRACT OR AGREEMENT YOU HAVE ENTERED INTO. PER THE CONTRACT OR AGREEMENT. Information required to complete this Schedule, if not shown above, will be shown in the Declarations. A. Section II – Who Is An Insured is amended to include as an additional insured the person(s) or organization(s) shown in the Schedule, but only with respect to liability for "bodily injury" or "property damage" caused, in whole or in part, by "your work" at the location designated and described in the Schedule of this endorsement performed for that additional insured and included in the "products-completed operations hazard". However: 1.The insurance afforded to such additional insured only applies to the extent permitted by law; and 2.If coverage provided to the additional insured is required by a contract or agreement, the insurance afforded to such additional insured will not be broader than that which you are required by the contract or agreement to provide for such additional insured. B.With respect to the insurance afforded to these additional insureds, the following is added to Section III – Limits Of Insurance: If coverage provided to the additional insured is required by a contract or agreement, the most we will pay on behalf of the additional insured is the amount of insurance: 1.Required by the contract or agreement; or 2.Available under the applicable limits of insurance; whichever is less. This endorsement shall not increase the applicable limits of insurance. CG 20 37 12 19 Page ofInsurance Services Office, Inc., 2018 1 1 GL5268212 POLICY NUMBER: PRIMARY AND NONCONTRIBUTORY - COMMERCIAL GENERAL LIABILITYCG 20 01 12 19 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. CG 20 01 12 19 Insurance Services Office, Inc., 2018 Page 1 of 1 OTHER INSURANCE CONDITION The following is added to the Other Insurance Condition and supersedes any provision to the contrary: Primary And Noncontributory Insurance 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. This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART LIQUOR LIABILITY COVERAGE PART PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE PART GL5268212 POLICY NUMBER: Insurance Services Office, Inc., 2018 Page 1 of 1 WAIVER OF TRANSFER OF RIGHTS OF RECOVERY AGAINST OTHERS TO US (WAIVER OF SUBROGATION) COMMERCIAL GENERAL LIABILITY CG 24 04 12 19 This endorsement modifies insurance provided under the following: SCHEDULE Name Of Person(s) Or Organization(s): Information required to complete this Schedule, if not shown above, will be shown in the Declarations. CG 24 04 12 19 The following is added to Paragraph 8. Transfer Of Rights Of Recovery Against Others To Us of Section IV – Conditions: We waive any right of recovery against the person(s) or organization(s) shown in the Schedule above because of payments we make under this Coverage Part. Such waiver by us applies only to the extent that the insured has waived its right of recovery against such person(s) or organization(s) prior to loss. This endorsement applies only to the person(s) or organization(s) shown in the Schedule above. COMMERCIAL GENERAL LIABILITY COVERAGE PART ELECTRONIC DATA LIABILITY COVERAGE PART LIQUOR LIABILITY COVERAGE PART POLLUTION LIABILITY COVERAGE PART DESIGNATED SITES POLLUTION LIABILITY LIMITED COVERAGE PART DESIGNATED SITES PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE PART RAILROAD PROTECTIVE LIABILITY COVERAGE PART UNDERGROUND STORAGE TANK POLICY DESIGNATED TANKS PURSUANT TO APPLICABLE WRITTEN CONTRACT OR AGREEMENT YOU ENTER INTO. GL5268212 ALTERNATE EMPLOYER ENDORSEMENT This endorsement changes the policy to which it is attached effective on the inception date of the policy unless a different date is indicated below. (The following "attaching clause" need be completed only when this endorsement is issued subsequent to preparation of the policy). This endorsement, effective 12:01 AM forms a part of Policy No. Issued to By This endorsement applies only with respect to bodily in- jury to your employees while in the course of special or temporary employment by the alternate employer in the state named in the schedule. Part One (Workers Com- pensation Insurance) and Part Two (Employers Liability Insurance) will apply as though the alternate employer is insured. Under Part One (Workers Compensation Insurance) we will reimburse the alternate employer for the benefits required by the workers compensation law if we are not permitted to pay the benefits directly to the persons en- titled to them. The insurance afforded by this endorsement is not in- tended to satisfy the alternate employer's duty to secure its obligations under the workers compensation law. We will not file evidence of this insurance on behalf of the alternate employer with any government agency. We will not ask any other insurer of the alternate em- ployer to share with us a loss covered by this endorse- ment. Premium will be charged for your employees while in the course of special or temporary employment by the al- ternate employer. The policy may be cancelled according to its terms without sending notice to the alternate employer. Part Four (Your Duties If Injury Occurs) applies to you and the alternate employer. The alternate employer will recognize our right to defend under Parts One and Two and our right to inspect under Part Six. Schedule Alternate Employer Address State of Special or Temporary Employment Halff Associates, Inc. New Hampshire Insurance Company ANY ALTERNATE EMPLOYER OF YOUR EMPLOYEES. WC 00 03 01 ______________________________ (Ed. 04/84) Countersigned by Authorized RepresentativePage of 11 WC01589376404/01/2023 KPG Psomas Inc.