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HomeMy WebLinkAboutPK16-357 - Other - EEOC - Roads Paving Washington, LLC - 06137 - 11/13/16 CITY OF KENT EQUAL EMPLOYMENT OPPORTUNITY COMPLIANCE STATEMENT This form shall be filled out AFTER COMPLETION of this project by the Contractor awarded the Agreement. I, the undersigned, a duly represented agent of rib Vln W/\ LL C . Company, hereby acknowledge and declare that the before-mentioned company was the prime contractor for the /Agre/ement known as ? cl)\0 1 2) that was entered into on the 9 I lG (date), between the firm I represent and the City of_ Kent. I declare that I complied fully with all of the requirements and obligations as outlined in the City of Kent Administrative Policy 1.2 and the Declaration City of Kent Equal Employment Opportunity Policy that was part of the before-mentioned Agreement. i By: For: �S lvira Title: E mccl IVl Date:_, (G i EEO COMPLIANCE DOCUMENTS - 3 f}R0f f Client#: 134570 ROADPAVI ACORD., CERTIFICATE F LIABILITY INSURANCE D101252016 10/25l2016 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). ACT PRODUCER NAME: Mattice Hoyt Propel Insurance (PA HONE,o UU:800 499.0933 ac Ne; 866 577.1326 Tacoma Commercial Insurance ADDRESS: Mattice.Hoyt@propelinsurance.com 1201 Pacific Ave,Suite 1000 INSURERS AFFORDING COVERAGE NAIL M Tacoma,WA 98402 INSURER A:Developers Surety&Indemnity C 12718 INSURED INSURER B:Ohio Security Insurance Company 24082 Roads Paving Washington LLC INSURER C 12514 SE 270th Street INSURER D Kent,WA 98030 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 FORTHE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACTOR 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. INSR TYPE OF INSURANCE ADDLSUB POLICY EFF POLICY UP LTR INSR MD POLICY NUMBER MM/DD MMIDD A X COMMERCIAL GENERAL LIABILITY X X BIS0001823202 2124/2016 02124/2017 EACH OCCURRENCE $2000000 CLAIMS-MADE O OCCUR PREMISES Ea oca,Enence $100 000 X PD Ded:2,000 MEDUP Any one person) I $5000 PERSONAL S ACV INJURY $2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $4,000,000 POLICY[ X1 JECOT LOC PRODUCTS-COMPIOP AGO $4 000 000 OTHER: $ IS AUTOMOBILE LIABILITY BAS56400770 10/29/2016 10129/201 E..cdd,mtsINGLE LIMIT S1,000,000 X ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY(Peraccident) $ AUTOS AUTOS NON-OWNED PROPERTYDAMAGE S X HIRED AUTOS X AUTOS Paraccidenf S UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED F1 RETENTION$ $ WORKERS COMPENSATION 7DISEASE ANO EMPLOYERS'LIABILITYA ANYCERIMEETOREXCLUERJEXECUTIVEY/NBISOOO1823202 2/241201602124/201 E.LCIDENT $1000000 OFFI(MandaRry 1.NHR EXCLUDED? IN] NIA (Mandatory In NH) (Stop Gap) E.L -EA EMPLOYEE $1 OOO OOOIf yes,describa under E.L -POLICY LIMIT $1,000,000 DESCRIPTION OF OPERATIONS below Tr__ _ DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 1DI,Additional Remarks Schedule,may be attached If more space Is required) RE: Operations Performed by the Named Insured City of Kent and their elected officials,officers,agents, employees and volunteers are Included as additional Insured as required by written contract and per attached endorsements. i CERTIFICATE HOLDER CANCELLATION Cif of Kent SHOULD ANYOFTHE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Y THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 220 Fourth Avenue South ACCORDANCE WITH THE POLICY PROVISIONS. Kent,WA 98032 AUTHORIZED REPRESENTATIVE ©1988.2014 ACORD CORPORATION.Al rights reserved. ACORD 25(2014101) 1 Of 1 The ACORD name and logo are registered marks of ACORD #S2451463/M2451455 LLM00 I This page has been left blank intentionally. i i i BIS0001823202 ID 00 37 04 13 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. BLANKET ADDITIONAL INSURED This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART A. Section II — Who Is An Insured is amended to include as an additional insured any person or organization for whom you are performing operations when you and such person or organization have agreed in writing in a contract or agreement that such person or organization be added as an additional insured on your policy. Such person or organization is an additional insured only with respect to liability for"bodily injury", "property damage" or"personal and advertising injury" caused by and to the extent of your negligence in the performance of your ongoing operations for the additional insured. A person's or organization's status as an additional insured under this endorsement ends when your operations for that additional insured are completed. B. With respect to the insurance afforded to these additional insureds, the following additional exclusions apply: This insurance does not apply to: 1. "Bodily injury", "property damage" or "personal and advertising injury" arising out of the rendering of, or the failure to render, any professional architectural, engineering or surveying services, including: a. The preparing, approving, or failing to prepare or approve, maps, shop drawings, opinions, reports, surveys, field orders, change orders or drawings and specifications; or b. Supervisory, inspection, architectural or engineering activities. 2. "Bodily injury"or"property damage"occurring after: a. 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 b. 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. 3. "Bodily Injur/', "property damage" or "personal and advertising injury' involving or related to or in connection with any additional insured or any location covered by a scheduled or blanket additional insured endorsement that is a part of the policy. C. Primary and Non-contributory Insurance - We will consider this insurance to be primary and non- contributory to other insurance issued directly to additional insured person(s) or organization(s) to which this endorsement applies if each such additional insured is a named insured in such other insurance and a written contract between you and such person(s) or organization(s) specifically requires that we consider this insurance to be primary and non-contributory.. D. Waiver of Subrogation—We waive any right of recovery we may have against the additional insured person(s) or organization(s) to which this endorsement applies if each such additional insured is a named insured in such other insurance and a written contract between you and such person(s) or organization(s) specifically requires that we waive subrogation of payments we make for injury or damage arising out of "your work" done under a contract with such person(s) or organization(s) to which this endorsement applies. ID 00 37 04 13 Page 1 of 1 This page has been left blank intentionally. I I I I I I° ID 00 37 04 13 l THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY, BLANKET ADDITIONAL INSURED This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART A. Section II — Who Is An Insured is amended to include as an additional insured any person or organization for whom you are performing operations when you and such person or organization have agreed in writing in a contract or agreement that such person or organization be added as an additional insured on your policy. Such person or organization is an additional insured only with respect to liability for"bodily injury", "property damage" or"personal and advertising injury" caused by and to the extent of your negligence in the performance of your ongoing operations for the additional insured. A person's or organization's status as an additional insured under this endorsement ends when your operations for that additional insured are completed. B. With respect to the insurance afforded to these additional insureds, the following additional exclusions apply: This insurance does not apply to: 1, "Bodily injury", "property damage" or "personal and advertising injury" arising out of the rendering of, or the failure to render, any professional architectural, engineering or surveying services, including: a. The preparing, approving, or failing to prepare or approve, maps, shop drawings, opinions, reports, surveys, field orders, change orders or drawings and specifications; or b. Supervisory, inspection, architectural or engineering activities. 2. "Bodily injury"or"property damage"occurring after: I a. 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 to. 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. 3. "Bodily injury", "property damage' or "personal and advertising injury' involving or related to or in connection with any additional insured or any location covered by a scheduled or blanket additional insured endorsement that is a part of the policy. C. Primary and Non-contributory Insurance - We will consider this insurance to be primary and non- contributory to other insurance issued directly to additional insured person(s) or organization(s) to which this endorsement applies if each such additional insured is a named insured in such other insurance and a written contract between you and such person(s) or organization(s) specifically requires that we consider this insurance to be primary and non-contributory.. D. Waiver of Subrogation—We waive any right of recovery we may have against the additional insured person(s) or organization(s) to which this endorsement applies if each such additional insured is a named insured in such other insurance and a written contract between you and such person(s) or organization(s) specifically requires that we waive subrogation of payments we make for injury or damage arising out of "your work" done under a contract with such person(s) or organization(s) to which this endorsement applies. 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