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HomeMy WebLinkAboutCity of Renton - COISHOULD 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) © 1988-2015 ACORD CORPORATION. All rights reserved. CERTIFICATE HOLDER The ACORD name and logo are registered marks of ACORD HIREDAUTOS ONLY 5/29/2025 Alliant Insurance Services,Inc.6400 S Fiddlers Green Cir Ste 2000GreenwoodVillageCO80111 Jennifer Bull Jennifer.Bull@alliant.com License#:0C36861 Liberty Mutual Insurance Company 23043 COLOSTR-02 Colorado Structures Inc.dba CSI Construction Company4724SMacadamAve.Portland,OR 97239 308913620 A X 2,000,000 X 100,000 10,000 1,000,000 4,000,000 X X Y TB2-691-464774-034 11/1/2024 11/1/2025 4,000,000 A 2,000,000 X Y AS2-691-464774-024 11/1/2024 11/1/2025 A X 1,000,000 X TH7-691-464774-044 11/1/2024Y 11/1/2025 1,000,000 Excess see attached 50,000,000 A X N WC2-691-464774-014 11/1/2024 11/1/2025 1,000,000 1,000,000 1,000,000 RE:Project #2183,Tesla 600 SW 10th Street Renton,WA 98057. See Attached... City of RentonAttention:Yong QI1055SouthGrady WayRentonWA98057 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: COLOSTR-02 1 1 Alliant Insurance Services,Inc.Colorado Structures Inc.dba CSI Construction Company4724SMacadamAve.Portland,OR 97239 25 CERTIFICATE OF LIABILITY INSURANCE City of Renton is named as Additional Insured with respect to General Liability,Auto Liability and Umbrella/Excess Liability if required by written contract.General Liability,Auto Liability and Umbrella/Excess Liability are primary,and any other insurance maintained by the Additional Insured is excess andnon-contributory.30 days’notice of cancellation or non-renewal will be provided to Certificate Holder,except 10 days’notice for cancellation for non-payment ofpremium. Total Excess Liability Limit: $50,000,0000. Insurer: Texas Insurance Company; 2nd Layer Excess, Policy Number: JTI24XCAN-02646-02, EƯ Date: 11/1/2024, Exp Date: 11/1/2025; Each Occ./Aggregate: $3M x $1M Insurer: Vantage Risk Specialty Insurance Company; 3rd Layer Excess, Policy Number: P03XC0000071050, EƯ Date: 11/1/2024, Exp Date: 11/1/2025; Each Occ./Aggregate: $5M x$4M Insurer: Associated Industries Insurance Company Inc; 4th Layer Excess, Policy Number: XSA1248771-00, EƯ Date: 11/1/2024, Exp Date: 11/1/2025; Each Occ./Aggregate: $8M p/o $16M x $9M Insurer: Endurance American Specialty Insurance Company; 4th Layer Excess, Policy Number: ELD30072233400, EƯ Date: 11/1/2024, Exp Date: 11/1/2025; Each Occ./Aggregate: $8M p/o $16M x $9M Insurer: Westfield Specialty Insurance Company, 5th Layer Excess, Policy Number: XSL-353210J- 01, EƯ Date: 11/1/2024, Exp Date: 11/1/2025; Each Occ./Aggregate: $15M x $25M Insurer: Fair American Select Insurance Company, 6th Layer Excess, Policy Number: CSX-8000644- 00, EƯ Date: 11/1/2024, Exp Date: 11/1/2025; Each Occ./Aggregate: $10M x $40M Insurer: Liberty Mutual Insurance Company; 1st Layer Excess, Policy Number: TH7-691-464774-044, EƯ Date: 11/1/2024, Exp Date: 11/1/2025; Each Occ./Aggregate: $1M x P CNA 90 15 11 16 © 2016 Liberty Mutual Insurance Page 1 of 1 2016 COMMERCIAL AUTO MISCELLANEOUS FORM REVISIONS ADVISORY NOTICE TO POLICYHOLDERS This Notice does not form part of your policy. No coverage is provided by this Notice nor can it be construed to replace any provision of your policy. You should read your policy and review your Declarations page for complete information on the coverages you are provided. If there is any conflict between the Policy and this Notice, THE PROVISIONS OF THE POLICY SHALL PREVAIL. Carefully read your policy, including the endorsements attached to your policy. This Notice provides information concerning the following forms and endorsements which apply to your renewal policy being issued by us. The forms and endorsements may reduce or broaden coverage. Broadening Of Coverage CA 04 49 – Primary And Noncontributory – Other Insurance Condition This endorsement is being introduced as an additional coverage option. When this endorsement is attached to your policy, the Other Insurance Condition in the Business Auto and Auto Dealers Coverage Forms and the Other Insurance – Primary And Excess Insurance Provisions in the Motor Carrier Coverage Form are revised to provide coverage to an "insured" on a primary and noncontributory basis, provided that certain conditions are met. Reductions Of Coverage CA 23 44 – Public Or Livery Passenger Conveyance Exclusion When this endorsement is attached to your policy, insurance provided under any applicable Covered Auto Liability, Physical Damage, Auto Medical Payments, Uninsured and/or Underinsured Motorists and Personal Injury Protection (or similar no-fault) Coverage is excluded while any covered auto is being used as a public or livery conveyance for passengers. This includes, but is not limited to, any period of time a covered auto is being used by an insured who is logged into a "transportation network platform" as a driver, whether or not a passenger is occupying the covered auto. CA 23 45 – Public Or Livery Passenger Conveyance And On-demand Delivery Services Exclusion When this endorsement is attached to your policy, insurance provided under any applicable Covered Auto Liability, Physical Damage, Auto Medical Payments, Uninsured and/or Underinsured Motorists and Personal Injury Protection (or similar no-fault) Coverage is excluded while any covered auto is being used: As a public or livery conveyance for passengers. This includes, but is not limited to, any period of time a covered auto is being used by an insured who is logged into a "transportation network platform" as a driver, whether or not a passenger is occupying the covered auto; or By an insured who is logged into a "transportation network platform" or "delivery network platform" as a driver to provide delivery services, which includes courier services, whether or not the goods, items or products to be delivered are in the covered auto. · · POLICY NUMBER: AS2-691-464774-024 Policy Number Issued by Liberty Mutual Fire Insurance Co. TB2-691-464774-034 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. OTHER INSURANCE AMENDMENT – SCHEDULED ADDITIONAL INSURED This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE PART LIQUOR LIABILITY COVERAGE PART If you are obligated under a written agreement to provide liability insurance on a primary, excess, contingent, or any other basis for any person(s) or organization(s) shown in the Schedule of this endorsement that qualifies as an additional insured on this Policy, this Policy will apply solely on the basis required by such written agreement and Paragraph 4. Other Insurance of Section IV – Conditions will not apply. Where the applicable written agreement does not specify on what basis the liability insurance will apply, the provisions of Paragraph 4. Other Insurance of Section IV – Conditions will apply. However, this insurance is excess over any other insurance available to the additional insured for which it is also covered as an additional insured for the same "occurrence", claim or "suit". Schedule Name of Person(s) or Organization(s): All persons or organizations with whom you have entered into a written contract or agreement, prior to an occurrence or offense, to provide additional insured status. Page of© 2018 Liberty Mutual Insurance Includes copyrighted material of Insurance Services Office, Inc., with its permission. 1 1LC 24 20 11 18