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HomeMy WebLinkAbout221099 KLB COI 06.01.22 - City of Renton.pdfSHOULD 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 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. $ $ $ $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 below If 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 HIRED AUTOS ONLY 206-343-2323 X X 5,000,000 X XX 88A5CA0000819 06/01/21 Coll $2,500 06/01/22 X Comp $2,000 X maria.moss@assuredpartners.com 1,000,000 38911 10690 23450 19720 Renton, WA 98057 X X 1055 South Grady Way 62468996 62468996 5,000 06/11/2021 This insurance is primary and non-contributory with a waiver of subrogation per the attached. 221099 affiliate required by contract. City of Renton, its officers, elected officials, employees, agents and authorized volunteers and any other City of Renton The following are additional insured per the attached: Project: 221099 Southport Park Ave X 88A5GL0000997 BERKLEY NATL INS CO ALLIED WORLD NATL ASSUR CO AMERICAN FAMILY HOME INS CO AMERICAN ALT INS CORP 06/01/22 06/01/22 06/01/22 USA 5,000,000 100,000 Seattle, WA 98101 X Mukilteo, WA 98275 X 06/01/21 KLB Construction, Inc. A P.O. Box 158 2,000,000 06/01/22 ashleywhite A D C 1325 Fourth Avenue, Suite 2100 X 93A2FF1000009 MKC11100038 0312-3586 1,000,000 2,000,000 1,000,000 X 1-206-343-2323 B 06/01/21 AssuredPartners of Wash. Ins. Agency, LLC CA Lic 0K61066 06/01/21 AssuredPartners of Washington, LLC 06/01/21 WA#877030 X 10,000 PD Deductible Maria Moss POLICY NUMBER: 88A5CA0000819 COMMERCIAL AUTO CA 20 48 10 13 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. DESIGNATED INSURED FOR COVERED AUTOS LIABILITY COVERAGE This endorsement modifies insurance provided under the following: AUTO DEALERS COVERAGE FORM BUSINESS AUTO COVERAGE FORM MOTOR CARRIER COVERAGE FORM With respect to coverage provided by this endorsement, the provisions of the Coverage Form apply unless modified by this endorsement. This endorsement identifies person(s) or organization(s) who are "insureds" for Covered Autos Liability Coverage under the Who Is An Insured provision of the Coverage Form. This endorsement does not alter coverage provided in the Coverage Form. This endorsement changes the policy effective on the inception date of the policy unless another date is indicated below. Endorsement Effective Date: SCHEDULE Name Of Person(s) Or Organization(s): As required by written contract Information required to complete this Schedule, if not shown above, will be shown in the Declarations. Each person or organization shown in the Schedule is an "insured" for Covered Autos Liability Coverage, but only to the extent that person or organization qualifies as an "insured" under the Who Is An Insured provision contained in Paragraph A.1. of Section II - Covered Autos Liability Coverage in the Business Auto and Motor Carrier Coverage Forms and Paragraph D.2. of Section I - Covered Autos Coverages of the Auto Dealers Coverage Form. © Insurance Services Office, Inc. POLICY NUMBER: 88A5CA0000819 COMMERCIAL AUTO CA 04 44 10 13 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. WAIVER OF TRANSFER OF RIGHTS OF RECOVERY AGAINST OTHERS TO US (WAIVER OF SUBROGATION) This endorsement modifies insurance provided under the following: AUTO DEALERS COVERAGE FORM BUSINESS AUTO COVERAGE FORM MOTOR CARRIER COVERAGE FORM With respect to coverage provided by this endorsement, the provisions of the Coverage Form apply unless modified by the endorsement. This endorsement changes the policy effective on the inception date of the policy unless another date is indicated below. Endorsement Effective Date: SCHEDULE Name(s) Of Person(s) Or Organization(s): As required by written contract Information required to complete this Schedule, if not shown above, will be shown in the Declarations. The Transfer Of Rights Of Recovery Against Others To Us condition does not apply to the person(s) or organization(s) shown in the Schedule, but only to the extent that subrogation is waived prior to the "accident" or the "loss" under a contract with that person or organization. © Insurance Services Office, Inc. All rights reserved. Includes copyrighted material of Insurance Services Office, Inc., with its permission. COMMERCIAL GENERAL LIABILITY GL 2045 06 14 Policy Number 88A5GL0000997 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. COMMERCIAL GENERAL LIABILITY ENHANCEMENT This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART Contents A.1. Amendment Of Liquor Liability Exclusion A.2. Non Owned Watercraft A.3. Personal Property Loaned Or In Your Care, Custody Or Control A.4. Damage To Rented Premises – Fire, Lightning Or Explosion B.1. Bail Bonds B.2. Loss Of Earnings C.1. Additional Insureds – Managers Or Lessors, Lessors Of Equipment, Governmental Agencies Or Political Subdivisions, Mortgagee, Assignee Or Receiver C.2. Newly Acquired Organizations Time Period D.1. Damage To Premises Rented To You Limit D.2. Medical Expense Limit E.1. Duties – Reporting As Worker's Compensation & Knowledge Of Occurrence E.2. Other Insurance – Fire, Lightning Or Explosion E.3. Representations – Unintentional Errors E.4. Waiver Of Rights Of Recovery F.1. Mental Anguish From Bodily Injury A. Paragraph 2. Exclusions of Section I – Coverages – Coverage A Bodily Injury And Property Damage Liability is amended as follows: 1. Amendment Of Liquor Liability Exclusion Exclusion c. Liquor Liability is replaced by the following: c. "Bodily injury" or "property damage" for which any insured may be held liable by reason of: (1) Causing or contributing to the intoxication of any person; (2) The furnishing of alcoholic beverages to a person under the legal drinking age or under the influence of alcohol; or (3) Any statute, ordinance or regulation relating to the sale, gift, distribution or use of alcoholic beverages. This exclusion applies even if the claims against any insured allege negligence or other wrongdoing in: (a) The supervision, hiring, employment, training or (b) Providing or failing to provide transportation with respect to any person that may be under the influence of alcohol; if the "occurrence" which caused the "bodily injury" or "property damage", involved that which is described in Paragraph (1), (2) or (3) above. GL 2045 06 14 Copyright, American Alternative Insurance Corporation, 2014. Page 1 of 5 All rights reserved. Includes copyrighted material of Insurance Services Office, Inc., with its permission. This exclusion applies only if you: (1) Manufacture, sell or distribute alcoholic beverages; (2) Serve or furnish alcoholic beverages for a charge whether or not such activity: (a) Requires a license; (b) Is for the purpose of financial gain or livelihood; or (3) Serve or furnish alcoholic beverages without a charge, if a license is required for such activity. However, this exclusion does not apply to "bodily injury" or "property damage" arising out of the selling, serving or furnishing of alcoholic beverages at functions sponsored, organized or hosted by you. For the purposes of this exclusion, permitting a person to bring alcoholic beverages on your premises, for consumption on your premises, whether or not a fee is charged or a license is required for such activity, is not by itself considered the business of selling, serving or furnishing alcoholic beverages. 2. Non Owned Watercraft Amendment Paragraph (2) of Exclusion g. Aircraft, Auto or Watercraft, item (a) is replaced by the following: (a) Less than 52 feet long; and 3. Property Damage to Personal Property Loaned To You Or In Your Care, Custody or Control Items (3) and (4) of exclusion j. Damage to Property are replaced by the following: (3) Property loaned to you; However, if your business is other than “contracting”, “servicing”, or rental, this exclusion does not apply to "property damage" to personal property that is loaned to you, but only if the damage is caused by your negligence. The most we will pay is $25,000 for each occurrence. This limit is part of the Each Occurrence Limit and not in addition to the Each Occurrence Limit. (4) Personal property in the care, custody or control of the insured; However, if your business is other than “contracting”, “servicing”, or rental, this exclusion does not apply to "property damage" to personal property that is in your care, custody or control, but only if the damage is caused by your negligence. The most we will pay is $25,000 for each occurrence. This limit is part of the Each Occurrence Limit and not in addition to the Each Occurrence Limit. If we have made any payment for property under Paragraph (3) above, we will not make any payment for that property under this Paragraph (4). 4. Damage To Premises Rented To You The last paragraph of 2. Exclusions is deleted and replaced by the following: Exclusions c. through n. do not apply to damage by fire, lightning or explosion to premises while rented to you or temporarily occupied by you with permission of the owner. A separate limit of insurance applies to this coverage as described in Section III – Limits of Insurance. B. Paragraphs 1.b. and 1.d. of Supplementary Payments – Coverages A And B are amended as follows: 1. Bail Bonds The limit for bail bonds in Paragraph 1.b. is amended to $2,500 in lieu of $250; and 2. Loss Of Earnings The limit for actual loss of earnings in Paragraph 1.d. is amended to $500 a day in lieu of $250 a day. C. Section II – Who Is An Insured is amended as follows: 1. The following are added as additional insureds when you have agreed in a written contract or written agreement that such person or organization be added as an additional insured on your policy: a. Managers Or Lessors Any managers or lessors of premises but only with respect to liability arising out of the ownership, maintenance or use of that part of the premises leased to you and subject to the following additional exclusions: Page 2 of 5 Copyright, American Alternative Insurance Corporation, 2014.l GL 2045 06 14 Services Office, Inc., with its permission. This insurance does not apply to: (1) Any "occurrence" which takes place after you cease to be a tenant in that premises. (2) Structural alterations, new construction or demolition operations performed by or on behalf of the person or organization from whom you rent or lease a premises. b. Lessors Of Equipment Any person or organization from whom you lease equipment. Such person or organization is an insured only with respect to liability for "bodily injury", "property damage" or "personal and advertising injury" caused, in whole or in part, by your maintenance, operation or use of equipment leased to you by such person or organization. A person’s or organization’s status as an additional insured under this endorsement ends when their contract or agreement with you for such leased equipment ends. c. Governmental Agencies Or Political Subdivisions Any state or governmental agency or subdivision or political subdivision subject to the following additional provisions: (1) This insurance applies only with respect to: (a) Premises you own, rent, or control; or (b) Operations performed by you or on your behalf; for which the state or governmental agency or subdivision or political subdivision has issued a permit or authorization. (2) This insurance does not apply to: (a) "Bodily injury", "property damage" or "personal and advertising injury" arising out of operations performed for the federal government, state or municipality; or (b) "Bodily injury" or "property damage" included within the "products-completed operations hazard". The written contract or written agreement referenced in paragraph 1. above must be; a. In effect at the inception of the policy period or become effective during the term of the policy period; and b. Executed prior to the “bodily injury”, “property damage”, “personal and advertising injury” covered under this coverage part. The Limits of Insurance applicable to the insureds in a., b., and c. above are those specified in the valid written contract or written agreement or in the Declarations for this policy, whichever is less. These Limits of Insurance are part of and not in addition to the Limits of Insurance shown in the Declarations. d. Mortgagee, Assignee Or Receiver Any person or organization who is a mortgagee, assignee or receiver of your premises or business, but only with respect to their liability as mortgagee, assignee, or receiver and arising out of the ownership, maintenance, or use of the premises by you. This insurance does not apply to structural alterations, new construction and demolition operations performed by or for that person or organization. 2. Paragraph 3.a. is replaced by the following: a. Coverage under this provision is afforded only until the 180th day after you acquire or form the organization or the end of the policy period, whichever is earlier; D. Section III – Limits of Insurance is amended as follows: 1. Paragraph 6. is replaced by the following: 6. Damage To Premises Rented To You Subject to Paragraph 5. above, the Damage To Premises Rented To You Limit is the most we will pay under Coverage A for damages because of “property damage” to any one premises; a. While rented to you; or GL 2045 06 14 Copyright, American Alternative Insurance Corporation, 2014. All rights reserved. Includes copyrighted material of Insurance Page 3 of 5 b. In the case of damage by fire, lightning or explosion, while rented to you or temporarily occupied by you with permission of the owner. The Damage To Premises Rented To You Limit is the greater of $1,000,000 or the limit shown on the Declarations page. 2. The following paragraph is added to item 7.: The Medical Expense Limit is the greater of $15,000 or the limit shown on the Declarations page. E. Section IV – Commercial General Liability Conditions is amended as follows: 1. The following is added to Condition 2. Duties in the Event of Occurrence, Offense, Claim or Suit: e. In the event that an insured reports an “occurrence” to the worker’s compensation carrier of the Named Insured, and this “occurrence” later develops into a General Liability claim to which this insurance applies, the failure to report such “occurrence” to us at the time of the “occurrence” shall not be deemed in violation of this condition. You must, however, give us notice as soon as practicable after being made aware that the particular claim is a General Liability claim rather than a Worker’s Compensation claim. f. If your “employee” or agent knows of an “occurrence” or offense which may result in a claim under this policy, you will not be considered to have knowledge of that “occurrence” or offense until your “employee” or agent reports it to: (1) You, if you are an individual; (2) A partner, if you are a partnership; (3) An “executive officer” or the “employee” designated by you to give notice to us of such “occurrence” or offense, if you are a corporation; (4) A manager, if you are a limited liability company; or (5) A trustee, if you are a trust. 2. Paragraph b. Excess Insurance of Condition 4. Other Insurance item (ii) of the Occurrence Form and item (iii) of the Claims Made Form is replaced by the following: That is Fire, Lightning or Explosion insurance for premises rented to you or temporarily occupied by you with permission of the owner; 3. The following is added to Condition 6. Representations: d. It will not be considered a violation of this condition if you: (1) Unintentionally fail to disclose all hazards existing at the inception of this policy; or (2) Unintentionally make an error, omission or provide an improper description of premises or other statement of information in applying for this insurance. You must notify us as soon as possible after the discovery of any hazards, errors or omissions in the information provided or any other relevant information that was not provided to us prior to the acceptance of this policy. 4. Condition 8. Transfer of Rights of Recovery Against Others To Us is amended by the addition of the following: We waive any right of recovery we may have against any person or organization because of payments we make for injury or damage if there is a contract, executed prior to the loss, with that person or organization that requires you to waive rights of recovery. F. Section V – Definitions is amended as follows: 1. Definition 3. in the Definitions Section is replaced by the following: 3. "Bodily injury” means bodily injury, sickness or disease sustained by a person including mental anguish, emotional distress, humiliation or death resulting from bodily injury, sickness or disease. Page 4 of 5 Copyright, American Alternative Insurance Corporation, 2014. All rights reserved. Includes copyrighted material of Insurance Services Office, Inc., with its permission. GL 2045 06 14 2. The following definitions are added: “Contracting” means an establishment in which the principal operation is that of installation, construction, demolition or maintenance. This includes any owner-contractor, general contractor or subcontractor, whether or not he/she actually performs any part of such work or has employees on the site. “Servicing” means an establishment in which the principal operation is the providing of a personal or commercial service. Included are establishments providing entertainment or recreation, or warehousing of property of others. GL 2045 06 14 Copyright, American Alternative Insurance Corporation, 2014. All rights reserved. Includes copyrighted material of Insurance Services Office, Inc., with its permission. Page 5 of 5 POLICY NUMBER: 88A5GL0000997 COMMERCIAL GENERAL LIABILITY CG 20 37 04 13 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 PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE PART SCHEDULE Name Of Additional Insured Person(s) Or Organization(s) Location And Description Of Completed Operations As required by written contract As required by written contract 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 shown in the Declarations; whichever is less. This endorsement shall not increase the applicable Limits of Insurance shown in the Declarations. © Insurance Services Office, Inc. ISO | Commercial General Liability Forms | 04/01/13 POLICY NUMBER: 88A5GL0000997 COMMERCIAL GENERAL LIABILITY CG 20 10 04 13 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) Or Organization(s) Location(s) Of Covered Operations As required by written contract As required by written contract 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", "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. 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 shown in the Declarations; whichever is less. This endorsement shall not increase the applicable Limits of Insurance shown in the Declarations. © Insurance Services Office, Inc. Policy No. 88A5GL0000997 COMMERCIAL GENERAL LIABILITY CG 20 01 04 13 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. PRIMARY AND NONCONTRIBUTORY - OTHER INSURANCE CONDITION This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE PART 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. © Insurance Services Office, Inc.