Loading...
HomeMy WebLinkAboutKnife River Certificate of Liability Insurance DATE(MM1DDIYYYY) ACQRa CERTIFICATE OF LIABILITY INSURANCE 0410312012 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE BOLDER. 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 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). PRODUCER CONTACT Marsh USA Inc. NAME: 333 SOUR}7111 Street,Si 1600 PHONE E I IAI No Minneapolis,MN 55402-2400 E-MAIL AODRESS: INSURER(S)AFFORDING COVERAGE NAIC rr J4375D JTLGE-GAX-12-13 2010 2037 2048 At N INSURER A:Liberty Mutual Fire Ins CD 23035 INSURED Kniife River-Belgrade,MT INSURER B:NIA NIA PO Box 9 INSURER C: Belgrade,MT 59714 INSURER D INSURER E INSURER F COVERAGES CERTIFICATE NUMBER: CHI-0044D8214-01 REVISION NUMBER: 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. INSR I TYPE OF INSURANCE IADDL SUBR POLICY EFF POLICY EXP LTR f N POLICYNUMBER MMIDDA'YYY I 1MM/DDNYYYJ LIMITS A GENERAL LIABILITY T82641OD5097-042 0110112012 QV0112013 EACH OCCURRENCE $ 2.000,000. X PRE S. a ocT�ence 5 COMMERCtAL GENERAL LIABILITY 50D,OD0 CLAIMS-MADE T OCCUR ME EXP(Any one person) $ 10,000 X PER PROJECT AGGREGATE PERSONAL 8,ADV INJURY S 2,000,000 GENERAL AGGREGATE $ 4,00D,ODa GEN'L AGGREGATE LIMIT APPLIES PER PRODUCTS-COMP/OP AGG $ 4,000.000 17 POLICY PRO I I LOC S A AUTOMOBILE LIABILITY AS2 641005097-052 0110112012 0110112013 EOMBINEDISINGLEwbir $ 2,000.000 qxANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY Per accident) g AUTOS AUTOS N ON-OWNED PROPERTY DAMAGE HIREDAUTOS AUTOS Peraccldenl S l S I UMBRELLA LAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMSMAOE AGGREGATE § OED RETENTION$ S WORKERS COMPENSATION WCSTA711 OTH- AND EMPLOYERS'LIABILITY ER A ANY PROPRIETOR/PARTNERIEXECU7IVE YIN N WA7.64D-005097-012(ADS) 01101/2012 01/01/2013 t,000,0a0 OFFICE"EMBER EXCLUDEO? NIA E.L.EACH ACCIDENT S (Mandatory in Ni "MT Employers Liability Only" E.L.DISEASE'EA EMPLOYE $ 1.0001060 if DyaS,dascrl N under E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS below 1,000,000 DESCRIPTION OF OPERATIONS!LOCATIONS/VEHICLES (Attach ACORD 101,Additional Remarks Schedule,if more space is required) Re:Downtown Bozeman Improvements District-Slruelscape Improvements Owner,and Engineer and Engineers Consultants islare included as additional insured per the attached CG 2010 and CG 2037 endorsements and does not include professional liability coverage. Blanket Additional Insured for Automobile Liabiliiy is included per attached designated Insured Endorsement CA 20 48. CERTIFICATE HOLDER CANCELLATION City of Bozeman SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE City Engineering THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN PO Box 1230 ACCORDANCE WITH THE POLICY PROVISIONS. Bozeman,MT 59771 AUTHORIZED REPRESENTATIVE or Marsh USA Inc. Manashi Mukherjee ©'1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010105) The ACORD name and logo are registered marks of ACORD Policy Number AS2-641-005097-052 Issued by LIBLI RTY MUTUAL FIRE INSURANCE COMPANY THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY, NOTICE OF CANCELLATION TO THIRD PARTIES This endorsement modifies insurance provided under the following: BUSINESS AUTO COVERAGE PART MOTOR CARRIER COVERAGE PART GARAGE COVERAGE PART TRUCKERS COVERAGE PART EXCESS AUTOMOBILE LIABILITY INDEMNITY COVERAGE PART SELF-INSURED TRUCKER EXCESS LIABILITY COVERAGE PART COMMERCIAL GENERAL LIABILITY COVERAGE PART EXCESS COMMERCIAL GENERAL LIABILITY COVERAGE PART PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE PART LIQUOR LIABILITY COVERAGE PART COMMERCIAL. LIABILITY — UMBRELLA COVERAGE FORM Schedule Name of Other Person(s)1 Email Address or mailing address: Number Days Notice: Organization(s): Per Schedule on file with the 90 company A. If we cancel this policy for any reason other than nonpayment of premium, we will notify the persons or organizations shown in the Schedule above. We will send notice to the entail or mailing address listed above at least 10 days, or the number of days listed above, if any, before the cancellation becomes eff ective. In no event does the notice to the third party exceed the notice to the first named insured. B. This advance notification of a pending cancellation of coverage is intended as a courtesy only. Our failure to provide such advance notification will not extend the policy cancellation date nor negate cancellation of the policy. All other terms and conditions of this policy remain unchanged. LIM 99 01 05 11 G 2011 Liberty Mutual Group of Companies.All rights reserved. Page I of 1 Includes copyrighted material of Insurance Services Office, Inc.,with its permission. Policy Number T112-641-005097-042 Issued by LIBERTY MUTUAL FIRE INSURANCE COMPANY THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. NOTICE OF CANCELLATION TO THIRD PARTIES This endorsement modifies insurance provided under the following: BUSINESS AUTO COVERAGE PART MOTOR CARRIER COVERAGE PART GARAGE COVERAGE PART TRUCKERS COVERAGE PART EXCESS AUTOMOBILE LIABILITY INDEMNITY COVERAGE PART SELF-INSURED TRUCKER EXCESS LIABILITY COVERAGE PART COMMERCIAL GENERAL LIABILITY COVERAGE PART EXCESS COMMERCIAL GENERAL LIABILITY COVERAGE PART PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE PART LIQUCR LEABILiTY COVERAGE PART COMMERCIAL LIABILITY— UMBRELLA COVERAGE FORM Schedule Name of Other Person(s)/ Email Address or mailing address: Number Days Notice: Organization(s): Per Schedule on file with the 90 company A. If we cancel this policy for any reason other than nonpayment of premium, we will notify the persons or organizations shown in the Schedule above. We will send notice to the email or mailing address listed above at least 10 days, or the number of days listed above, if any, before the cancellation becomes effective. In no event does the notice to the third party exceed the notice to the first named insured. B. This advance notification of a pending cancellation of coverage is intended as a courtesy only. Our failure to provide such advance notification will not extend the policy cancellation date nor negate cancellation of the policy. All other terms and conditions of this policy remain unchanged. LIM 99 01 05 11 Q 2011 Liberty Mutual Group of Companies. All rights reserved. Pagel of 1 Includes copyrighted material of Insurance Services Office, Inc.,with its permission, THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. NOTICE OF CANCELLATION TO THIRD PARTIES A. If we cancel this policy for any reason other than nonpayment of premium, we will notify the persons or organizations shown in the Schedule below. We will send notice to the email or mailing address listed below at least 10 days, or the number of days listed below, if any, before cancellation becomes effective. In no event does the notice to the third party exceed the notice to the first named insured. B. This advance notification of a pending cancellation of coverage is intended as a courtesy only. Our failure to provide such advance notification will not extend the policy cancellation date nor negate cancellation of the policy. SCHEDULE Name of Other Person(s)! Email Address or mailing address: Number Days Notice: Organization(s): Per Schedule on file with the 90 company AI[other terms and conditions of this policy remain unchanged. Issued by L4BERTY INSURANCE CORPORATION For attachment to Policy No. VVA7-64D-005097-012 Effective date 01101/2012 Premium $ Issued to WM 90 18 06 11 O 2011 Liberty Mutual Group of Companies Page 1 of 1 Ed. 06101!2011 All Rights Reserved THIS ENDORSEMENT CHANGES THE POLICY. PLEASE REAL]IT CAREF=ULLY. DESIGNATED INSURED This endorsement modified insurance provided under the following: BUSINESS AUTO COVERAGE FORM GARAGE COVERAGE FORM MOTOR CARRIER COVERAGE FORM TRUCKERS COVERAGE FORM :Nith respect to coverage provided by this endorsement,the provisions of the Coverage F=orm apply unless modified by this endorsement. This endorsement identifies person(s) or organization(s)who are"insureds" under the Who Is An Insured Provision of the Coverage Form. This endorsement does not alter coverage provided in the Coverage Form, SCHEDULE Name of Person(s) or Any person or organization wham you hack agreed in writing to add as an additional Organization(s): Insured,but only to coverageand:nirumurr:limitsof ins wancereguiredby the wzitten agreement and in no event to exceed either the scope of coverage or the Lmits of insurance provided in this policy. Each person or organization shown in the Schedule is an"insured"for Liability Coverage,but only to the extent that person or organization qualifies as an"insured"under the Who Is An Insured Provision contained in Section 11 of the Coverage Form. Policy No: AS2-641-005097-052 Issued By: Laberty Mutual Fire Insurance Company Effective Date: 1/112012 Expiration Date: 1/1/2013 CA 20 48 02 99 Copyright, Insurance Services Office, Inc., 1998 Page 1 of'I THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. 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) Location And Description Of Completed Operations Or Organization(s): Any person or organization for whore you have agreed in writing prior to a loss to provide liability insurance Information required to complete this Schedule, if not shown above,will be shown in the Declarations. Section 11 — 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 dam- age" caused, in whole or in part, by "your work" at the location designated and described in the sched- ule of this endorsement performed for that additional insured and included in the "products-completed operations hazard". This endorsa3ieni is executod by she LIBERTY MUTUAL FIRE INS URANGE COMPANY Fremiurti $ Gffeclive pate 111/2012 Expiration Date 111/2013 For allachmenllo Policy No. TB2-641-005097-042 Audit Basis Issued To CG 20 37 07 04 Cr 150 Properties, Inc.,2004 page t of 1 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY, ADDITIONAL INSURED - OWNERS, LESSEES OR CONTRACTORS - SCHEDULED PERSON OR ORGANIZATION This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Name Of Additional Insured Person(s) Location(s) Of Covered Operations Or Organization(s): Any owner, lessee or contractor from whom you have agreed in writing prior to a loss to provide liability insurance Information required to complete this Schedule,if not shown above,will be shown in the Declarations. A. Section li — Who Is An Insured is amended to S. With respect to the insurance afforded to these include as an additional insured the person(s) or additional insureds, the following additional exclu- organization(s) shown in the Schedule, but only siorns apply: with respect to liability for "bodily injury", "property This insurance does not apply to "bodily Ap Y y injury" or damage" or "personal and advertising injury" "properly damage"occurring after: caused,in whole or in part, by: 1. Your acts or omissions; or 1. All work, including materials, parts or equip- ment furnished in connection with such work, 2. The acts or omissions of those acting on your on the project(other than service, maintenance behalf; or repairs) to be performed by or on behalf of in the performance of your ongoing operations for the additional insured(s) at the location of the the additional insured(s) at the location(s) desig- covered operations has been completed; or nated above. CG 20 10 07 04 G ISO Properties, Inc., 2004 Page 1 of 2 2. That portion of "your work" out of which the injury or damage arises has been put to its in- tended use by any person or organization other than another contractor or subcontractor en- gaged in performing operations for a principal as a part of the same project. This endorsemenl is executed by the LIBERTY MUTUAL FIRE INSURANCE COMPANY Premium $ Effective Dale 111/2012 Expiration Date 11112013 For attachment to Folicy No. TB2-041-005097-042 Audit Basis Issued To Page 2 of 2 () ISO Properties, Inc.,2004 CG 2G 10 07 04 Client#:4861 MTCONTRA YYYY} ACORDT. CERTIFICATE OF LIABILITY INSURANCE 4103 RATE(MMfDDfMIDDI 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 be endorsed.If SUBROGATION IS WAIVER,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). PRODUCER CONTACT NAME: Hoiness LaBar Insurance PHONE FAX I JP No EXq:40fi-238-1900 No}, A Member of Payne Financial Group E-MAIL ADDRESS: P.O. Box 30638 INSURER(S)AFFORDING COVERAGE NAIC# Billings, MT 59107-0638 INSURERA:Safety National Cas.Corp. INSURER INSURER B; Knife River-Belgrade INSURER C A Member of the MCCF INSURER D: PO Box 9 Belgrade, MT 59714 INSURER E: INSURER F COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: 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 CONTRACTOR 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. INSR TYPE OF INSURANCE ADDLSUBR POLICY EFF POLICY EXP LIMITS LTR [NSA VVVD POLICYNUMBER MMIDDIYYYY MMIDDIYYYY GENERAL LIABILITY EACH OCCURRENCE S COMMERCIAL GENERAL LIABILITY PR M GE ES Ea oeou RENTED 5 CLAIMS-MADE []OCCUR MED EXP(Any one person) 5 PERSONAL&ADV INJURY S GENERAL AGGREGATE S GEN'L AGGREGATE LIMIT APPLIES PER: PROiaJOTS-COMPlOP AGG S POLICY PRO EGT F I LOC S J AUTOMOBILE LIABILITY COtdBINED SINGLE LIMIT Ea accident. S ANY AUTO BODILY INJURY(Per parson) S ALL OWNED SCHEDULED AUTOS AUTOS BODILY INJURY(Per accident) $ NON-OWNED PROPERTY DAMAGE $ HIREDAUTOS AUTOS Peracudenl UMBRELLA LIAB OCCUR EACH OCCURRENCE S EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED I I RETENTION$ $ WORKERS COMPENSATION WC STATU- OTH- AND EMPLOYERS'LIABILITY Y I N ER ANY PROPRIETORIPARTNERIEXECUTIVE❑ E.L.EACH ACCIDENT $ OFFICERIMEMBER EXCLUDED? NIA (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE S If yes.,describe under DFSCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT S A Workers Comp SP4045598 0 1101/2012 01/0112 013 Coverage A—Statutory Employers Liab Excluded DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(Attach ACORD 101,Additional Remarks Schedule,if more space is required) Subject to the terms and conditions of the policy as issued by the Insurance Company. SIR for Work Comp$1,000,000 per occurrence. Covers Montana State Resident Employees. All claims are administered by the Montana Contractor Compensation Fund(MCCF). JOB: Downtown Bozeman Improvements District Streetscape Improvements CERTIFICATE HOLDER CANCELLATION City Of B SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE y Bozeman THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN City Engineering ACCORDANCE WITH THE POLICY PROVISIONS. PO Box 1230 Bozeman, MT 59771 AUTHORIZED REPRESENTATIVE 1988-2010 ACORD CORPORATION.All rights reserved. ACORD 25(2040105) 1 of 1 The ACORD name and logo are registered marks of ACORD #S7567061M749348 VE1