Loading...
HomeMy WebLinkAboutCertificate of Insurance for Saybr ContractorsANY PROPRIETOR/PARTNER/EXECUTIVEOFFICER/MEMBER EXCLUDED? INSR ADDL SUBRLTRINSDWVD 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) 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 EACH OCCURRENCE $ DAMAGE TO RENTEDCLAIMS-MADE OCCUR $PREMISES (Ea occurrence) MED EXP (Any one person)$ PERSONAL & ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER:GENERAL AGGREGATE $ PRO-POLICY LOC PRODUCTS - COMP/OP AGGJECT OTHER:$ COMBINED SINGLE LIMIT $(Ea accident) ANY AUTO BODILY INJURY (Per person)$ OWNED SCHEDULED BODILY INJURY (Per accident)$AUTOS ONLY AUTOS HIRED NON-OWNED PROPERTY DAMAGE $AUTOS ONLY 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 LIMITDESCRIPTION OF OPERATIONS below INSURER(S) AFFORDING COVERAGE NAIC # COMMERCIAL GENERAL LIABILITY Y / N N / A (Mandatory in NH) 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 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.ACORD 25 (2016/03) CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DD/YYYY) $ $ $ $ $ The ACORD name and logo are registered marks of ACORD 6/30/2023 (425) 489-4500 (425) 485-8489 41297 Saybr Contractors Inc 3852 South 66th St Tacoma, WA 98409-2408 15377 A 1,000,000 X X VRS0006769 7/1/2023 7/1/2024 50,000 5,000 1,000,000 2,000,000 2,000,000 WA STOP GAP 1,000,000 1,000,000B X X CPP 1235427 7/1/2023 7/1/2024 5,000,000A X X VES0004186 7/1/2023 7/1/2024 5,000,000 A VRS0006769 7/1/2023 7/1/2024 1,000,000 1,000,000 1,000,000 A Pollution Liability VRS0006769 7/1/2023 Occ: $1,000,000 Agg:2,000,000 RE: Project #C23000456, XPO Logistics Filtration Facility. City Of Renton is included as Additional Insured, coverage is Primary and Non-Contributory, and Waiver of Subrogation applies per the attached forms/endorsements. Per Project Aggregate applies to General Liability policy, per attached forms/endorsements. City Of Renton Attn: 1st Floor Finance 1055 s. Grady Way Renton, WA 98057 SAYBCON-01 LVASUPALLI Hub International Northwest LLC PO Box 3018 Bothell, WA 98041 now.info@hubinternational.com Scottsdale Insurance Company Western National Mutual Insurance Company X 7/1/2024 X X X X X X Policy # Effective Date: 7/01/2023 Expiration Date: 7/01/2024 VRS0006769 Policy # Effective Date: 7/01/2023 Expiration Date: 7/01/2024 VRS0006769 POLICY NUMBER: COMMERCIAL EXCESS LIABILITY CX 24 33 11 16 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. NONCONTRIBUTORY - OTHER INSURANCE CONDITION This endorsement modifies insurance provided under the following: COMMERCIAL EXCESS LIABILITY COVERAGE PART SCHEDULE Name Of Additional Insured Person(s) Or Organization(s): All Projects of the Insured but only to the extent that valid controlling underlying insurance is provided on a primary and noncontributory basis for written contracts. Information required to complete this Schedule, if not shown above, will be shown in the Declarations. Paragraph 8. of Section III - Conditions is replaced by the following: 8. Other Insurance a.This insurance is excess over, and shall not contribute with any of the other insurance, whether primary, excess, contingent or on any other basis. However: (1)This condition will not apply to other insurance specifically written as excess over this Coverage Part. (2)The insurance provided under this Coverage Part will not seek contribution from any other insurance available to an additional insured, provided that: (a)The additional insured is a NamedInsured under such other insurance; (b)The additional insured is shown in the Schedule; and (c)You have agreed in writing in a contract or agreement that this insurance would not seek contribution from any other insurance available to the additional insured. When this insurance is excess, if no other insurer defends, we will undertake to do so, but we will be entitled to the insured's rights against all those other insurers. b.When this insurance is excess over other insurance, we will pay only our share of the "ultimate net loss" that exceeds the sum of: (1)The total amount that all such other insurance would pay for the loss in the absence of the insurance provided under this Coverage Part; and (2)The total of all deductible and self-insuredamounts under all that other insurance. CX 24 33 11 16 © Insurance Services Office, Inc., 2016 Page 1 of 1 VES0004186 Policy# Effective Date 07/01/2023 Expiration Date 07/01/2024 VES0004186