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HomeMy WebLinkAboutCert of Insurance Kittitas County namedDATE (MM/DD/YYYY)CERTIFICATE OF LIABILITY INSURANCE 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 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). CONTACTPRODUCERNAME: FAXPHONE (A/C, No):(A/C, No, Ext): E-MAIL ADDRESS: INSURER(S) AFFORDING COVERAGE NAIC # INSURER A : INSURED INSURER B : INSURER C : INSURER D : 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 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. ADDL SUBRINSR POLICY EFF POLICY EXPTYPE OF INSURANCE LIMITSPOLICY NUMBERLTR (MM/DD/YYYY)(MM/DD/YYYY)INSD WVD COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ DAMAGE TO RENTED CLAIMS-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 AGG $JECT $OTHER: COMBINED SINGLE LIMITAUTOMOBILE LIABILITY $(Ea accident) BODILY INJURY (Per person)$ANY AUTO ALL OWNED SCHEDULED BODILY INJURY (Per accident)$AUTOS AUTOS NON-OWNED PROPERTY DAMAGE $HIRED AUTOS (Per accident)AUTOS $ UMBRELLA LIAB EACH OCCURRENCE $OCCUR EXCESS LIAB CLAIMS-MADE AGGREGATE $ $DED RETENTION $ PER OTH-WORKERS COMPENSATION STATUTE ERAND EMPLOYERS' LIABILITY Y / N ANY PROPRIETOR/PARTNER/EXECUTIVE E.L. EACH ACCIDENT $N / AOFFICER/MEMBER EXCLUDED? (Mandatory in NH)E.L. DISEASE - EA EMPLOYEE $ If yes, describe under E.L. DISEASE - POLICY LIMIT $DESCRIPTION OF OPERATIONS below DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE © 1988-2014 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORDACORD 25 (2014/01) CLEAHAR-01 SHELTONJE 3/24/2016 Willis Towers Watson Certificate Center Willis of Massachusetts, Inc. c/o 26 Century Blvd P.O. Box 305191 Nashville, TN 37230-5191 (877) 945-7378 (888) 467-2378 Certificates@willis.com ACE American Insurance Company 22667 Thermo Fluids Inc. 14624 N. Scottsdale Rd., Suite 300 Scottsdale, AZ 85254 American Guarantee and Liability Insurance Company 26247 Indemnity Insurance Company of North America 43575 A X 2,000,000 X X X HDOG2740067A 11/01/2015 11/01/2016 500,000 X XCU 5,000 X Contractual 2,000,000 4,000,000 X X 4,000,000 5,000,000 A X X X ISAH08860889 11/01/2015 11/01/2016 X X X MCS-90 XX 10,000,000 B AUC 4275262-11 11/01/2015 11/01/2016 10,000,000 0X X C X WLRC48592739 (AOS)11/01/2015 11/01/2016 2,000,000N 2,000,000 2,000,000 A Workers Compensation WLRC48592715 (AZ, CA, MA)11/01/2015 11/01/2016 See Attached Kittitas County is named as an Additional Insured for General Liability and Auto Liability as their interests may appear if required by written contract but only with respect to liability arising out of operations of the Named Insured. It is understood and agreed that the company waives its right of subrogation which may arise by reason of a payment of claim under the General Liability, Auto Liability, Worker's Compensation policy(ies) as required by written contract where allowed by state law. Kittitas County 925 S. Industrial Way Ellensburg, WA 98926 ADDITIONAL COVERAGE SCHEDULE COVERAGE LIMITS POLICY TYPE: Workers Compensation & Employers Liability CARRIER: ACE American Insurance Company POLICY TERM: 11/01/2015 - 11/01/2016 POLICY NUMBER: WLRC48592715 (AZ, CA, MA) Work Comp - Per Statute E.L. Each Accident $2,000,000 E.L. Disease - Policy Limit $2,000,000 E.L. Disease - Each Employee $2,000,000 POLICY TYPE: Professional Liability CARRIER: Illinois Union Insurance Company POLICY TERM: 11/01/2015 - 11/01/2016 POLICY NUMBER: COO G27416603 001 $10,000,000 Each Claim $10,000,000 All Claims $250,000 SIR POLICY TYPE: Contractors Pollution CARRIER: Illinois Union Insurance Company POLICY TERM: 11/01/2015 – 11/01/2016 POLICY NUMBER: COO G27416603 001 $10,000,000 Each Claim $10,000,000 All Claims $250,000 SIR