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HomeMy WebLinkAboutCityofBremerton_W38380659 (1)SHOULD 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.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 03/27/2025 COIRequest@crowncastle.com ACE American Insurance Company 22667 W38380659 A 2,000,000 1,000,000 10,000 2,000,000 4,000,000 4,000,000 Y Y HDO G48933889 04/01/2025 04/01/2026 A 2,000,000 04/01/202604/01/2025YYISA H11357131 A 5,000,000 25,000 Y Y XEUG47458262 002 04/01/2025 04/01/2026 5,000,000 WLR C72611251AY 1,000,000No04/01/2025 04/01/2026 1,000,000 1,000,000 389302927488978SR 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.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 W38380659CERT:3893029BATCH:27488978SR ID: 1 ALL-32686 (01/11)Page 1 of 1 NOTICE TO OTHERS ENDORSEMENT – SCHEDULE NOTICE BY INSURED'S REPRESENTATIVENOTICE TO OTHERS ENDORSEMENT – SCHEDULE NOTICE BY INSURED'S REPRESENTATIVE Named Insured Crown Castle Inc.Endorsement Number 3 Policy Symbol ISA Policy Number H11357131 Policy Period 04/01/2025 TO 04/01/2026 Effective Date of Endorsement Issued By (Name of Insurance Company) ACE American Insurance Company Insert the policy number. The remainder of the information is to be completed only when this endorsement is issued subsequent to the preparation of the policy. THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. A.If we cancel this Policy prior to its expiration date by notice to you or the first Named Insured for any reason other than nonpayment of premium,we will endeavor,as set out in this endorsement,to send written notice of cancellation,to the persons or organizations listed in the schedule that you or your representative create or maintain (the “Schedule”) by allowing your representative to send such notice to such persons or organizations.This notice will be in addition to our notice to you or the first Named Insured,and any other party whom we are required to notify by statute and in accordance with the cancellation provisions of the Policy. B.The notice referenced in this endorsement as provided by your representative is intended only to be a courtesy notification to the person(s)or organization(s)named in the Schedule in the event of a pending cancellation of coverage.We have no legal obligation of any kind to any such person(s)or organization(s).The failure to provide advance notification of cancellation to the person(s)or organization(s)shown in the Schedule will impose no obligation or liability of any kind upon us,our agents or representatives,will not extend any Policy cancellation date and will not negate any cancellation of the Policy. C.We are not responsible for verifying any information in any Schedule,nor are we responsible for any incorrect information that you or your representative may use. D.We will only be responsible for sending such notice to your representative,and your representative will in turn send the notice to the persons or organizations listed in the Schedule at least 30 days prior to the cancellation date applicable to the Policy.You will cooperate with us in providing the Schedule,or in causing your representative to provide the Schedule. E.This endorsement does not apply in the event that you cancel the Policy. All other terms and conditions of this Policy remain unchanged. Authorized Representative 1 ALL-32686 (01/11)Page 1 of 1 NOTICE TO OTHERS ENDORSEMENT – SCHEDULE NOTICE BY INSURED'S REPRESENTATIVE NOTICE TO OTHERS ENDORSEMENT – SCHEDULE NOTICE BY INSURED'S REPRESENTATIVE Named Insured Crown Castle Inc.Endorsement Number 6 Policy Symbol HDO Policy Number G48933889 Policy Period 04/01/2025 TO 04/01/2026 Effective Date of Endorsement Issued By (Name of Insurance Company) ACE American Insurance Company Insert the policy number. The remainder of the information is to be completed only when this endorsement is issued subsequent to the preparation of the policy. THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. A.If we cancel this Policy prior to its expiration date by notice to you or the first Named Insured for any reason other than nonpayment of premium,we will endeavor,as set out in this endorsement,to send written notice of cancellation,to the persons or organizations listed in the schedule that you or your representative create or maintain (the “Schedule”) by allowing your representative to send such notice to such persons or organizations.This notice will be in addition to our notice to you or the first Named Insured,and any other party whom we are required to notify by statute and in accordance with the cancellation provisions of the Policy. B.The notice referenced in this endorsement as provided by your representative is intended only to be a courtesy notification to the person(s)or organization(s)named in the Schedule in the event of a pending cancellation of coverage.We have no legal obligation of any kind to any such person(s)or organization(s).The failure to provide advance notification of cancellation to the person(s)or organization(s)shown in the Schedule will impose no obligation or liability of any kind upon us,our agents or representatives,will not extend any Policy cancellation date and will not negate any cancellation of the Policy. C.We are not responsible for verifying any information in any Schedule,nor are we responsible for any incorrect information that you or your representative may use. D.We will only be responsible for sending such notice to your representative,and your representative will in turn send the notice to the persons or organizations listed in the Schedule at least 30 days prior to the cancellation date applicable to the Policy.You will cooperate with us in providing the Schedule,or in causing your representative to provide the Schedule. E.This endorsement does not apply in the event that you cancel the Policy. All other terms and conditions of this Policy remain unchanged. Authorized Representative WC 99 03 69 (01/11)Page 1 Workers' Compensation and Employers' Liability Policy Named Insured CROWN CASTLE INC. 1500 CORPORATE DR CANONSBURG PA 15317 Endorsement Number Policy Number Symbol:WLR Number:C72611251 Policy Period 04-01-2025 TO 04-01-2026 Effective Date of Endorsement 04-01-2025 Issued By (Name of Insurance Company) ACE AMERICAN INSURANCE COMPANY Insert the policy number. The remainder of the information is to be completed only when this endorsement is issued subsequent to the preparation of the policy. This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated. NOTICE TO OTHERS ENDORSEMENT – SCHEDULE NOTICE BY INSURED’S REPRESENTATIVE A.If we cancel this Policy prior to its expiration date by notice to you or the first Named insured for any reason other than nonpayment of premium,we will endeavor,as set out in this endorsement,to send written notice of cancellation,to the persons or organizations listed in the schedule that you or your representative create or maintain (the “Schedule”) by allowing your representative to send such notice to such persons or organizations.This notice will be in addition to our notice to you or the first Named Insured,and any other party whom we are required to notify by statute and in accordance with the cancellation provisions of the Policy. B.The notice referenced in this endorsement as provided by your representative is intended only to be a courtesy notification to the person(s)or organization(s)named in the Schedule in the event of a pending cancellation of coverage.We have no legal obligation of any kind to any such person(s)or organization(s).The failure to provide advance notification of cancellation to the person(s)or organization(s)shown in the Schedule will impose no obligation or liability of any kind upon us,our agents or representatives,will not extend any Policy cancellation date and will not negate any cancellation of the Policy. C.We are not responsible for verifying any information in any Schedule,nor are we responsible for any incorrect information that you or your representative may use. D.We will only be responsible for sending such notice to your representative,and your representative will in turn send the notice to the persons or organizations listed in the Schedule at least 30 days prior to the cancellation date applicable to the Policy.You will cooperate with us in providing the Schedule,or in causing your representative to provide the Schedule. E.This endorsement does not apply in the event that you cancel the Policy. All other terms and conditions of this Policy remain unchanged. This endorsement is not applicable in the states of AZ, FL, ID, ME, NC, NJ, NM, TX and WI. Authorized Representative