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HomeMy WebLinkAboutCertificate of Insurance for Renton School District No. 403INSR 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 Phoenix Insurance Company Travelers Property Cas. Co. of America Travelers Indemnity Company 3/03/2023 USI Insurance Services, LLC P.O. Box 7050 Englewood, CO 80155 800 873-8500 Sheila Bartlett 800 873-8500 den.contractors@usi.com Cornerstone General Contractors, Inc. 11805 North Creek Pkwy S, #A-115 Bothell, WA 98011 25623 25674 25658 A X X X BI/PD Ded:25000 X DTCO5G613265PHX23 01/01/2023 01/01/2024 1,000,000 500,000 5,000 1,000,000 2,000,000 2,000,000 C X XDrive Oth Car X X 8102L9300622326G 01/01/2023 01/01/2024 1,000,000 B X X X 10,000 CUP1W8833902326 01/01/2023 01/01/2024 13,000,000 13,000,000 A Washington Stop Gap DTCO5G613265PHX23 01/01/2023 01/01/2024 $1,000,000 Ea Accident $1,000,000 By Disease $1,000,000 Ea Employee Professional Liability and Pollution Liability Policy COOG47381095001 effective 01/01/2023 to 01/01/2025 Insurer: Illinois Union Insurance Company Limits: $2,000,000 each claim, $2,000,000 aggregate Deductible: $25,000 (See Attached Descriptions) Renton School District No. 403 300 SW 7th Street Renton, WA 98057 1 of 2 #S39287932/M38710612 CORNEGEN1Client#: 1083272 NEKZP 1 of 2 #S39287932/M38710612 SAGITTA 25.3 (2016/03) DESCRIPTIONS (Continued from Page 1) RE: Lindbergh High School Phased Modernization, 16426 128th Avenue SE, Renton, Washington 98058 The General Liability policy includes an automatic Additional Insured endorsement that provides Additional Insured status to Renton School District No. 403, City of Renton, its directors, officers, and agents, only when there is a written contract that requires such status, and only with regard to work performed by or on behalf of the named insured. The General Liability policy contains a special endorsement with Primary and Noncontributory wording, when required by written contract. The General Liability policy includes a Waiver of Subrogation endorsement in favor of the Certificate Holder as referenced above. 2 of 2 #S39287932/M38710612