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HomeMy WebLinkAboutPW15-059 - Insurance Certificate - Verizon - 06/30/2019-06/30/2020 Coverage - 05/18/2019 DATE(MM/DD/YYYY) CERTIFICATE OF LIABILITY INSURANCE 06/18/2019 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 co 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). PRODUCER CONTACT 'O NAME: Aon Risk Services Northeast, Inc. Recie, PHONE FAX New York NY Office (A/C.No.Ext): (866) 283-7122 (AC.No.): (800) 363-0105 one Liberty Pl , /� E165 Broadway, suite 3201v DDRIsui ESS: 2 New York NY 10006 USA INSURER(S)AFFORDING COVERAGE NAIC# INSURED �, rf U INSURER A: National Union Fire Ins CO of Pittsburgh 19445 verizon Communications Inc. CC. 20+y INSURER B: 1095 Avenue of the Americas •V New York NY 10036 USA INSURER C: C17y of INSURER D: Cl)y C fi INSURER F: COVERAGES CERTIFICATE NUMBER: 570076856042 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. Limits shown are as requested LTR TYPE OF INSURANCE NSD WVD POLICY NUMBER MMIDD/YYYY MM/DD/YYYY LIMITS A X COMMERCIAL GENERAL LIABILITY GL EACH OCCURRENCE $5,000,000 DAMAGE TO RENTED CLAIMS-MADE X❑OCCUR PREMISES(Ea occurrence $5,OOO,OOO X Standard Contractual Liability MED EXP(Any one person) $10,000 PERSONAL&ADV INJURY $5,000,000 N X XCU Coverage is Included o GEN'LAGGREGATE LIMITAPPLIES PER: GENERAL AGGREGATE $5,000,000 PRO- OD X POLICY ❑JECT LOC PRODUCTS-COMP/OPAGG $5,OOO,OOO 0 O OTHER: o A CA 299-19-14 06/30/2019 06/30/2020 COMBINED SINGLE LIMIT AUTOMOBILE LIABILITY $5,000,00O A05 Ea accident A X ANYAUTO CA 299-19-18 06/30/2019 06/30/2020 BODILY INJURY(Per person) Z OWNED SCHEDULED MA BODILY INJURY(Per accident) d A AUTOS ONLY AUTOS CA 299-19-15 06/30/2019 06/30/2020 PROPERTY DAMAGE V HIREDAUTOS NON-OWNED VA ONLY AUTOS ONLY Per accident) Y- A see Next Page 06/30/2019 06/30/2020 y UMBRELLA LIAB HOCCUR EACH OCCURRENCE V EXCESS LIAB CLAIMS-MADE AGGREGATE DED RETENTION WORKERS COMPENSATION AND PER OTH- EMPLOYERS'LIABILITY Y/N STATUTE ER ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT OFFICER/MEMBER EXCLUDED? ❑ N/A (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space is required) Named insured includes: Cellco Partnership dba Verizon Wireless, 180 Washington valley Road, Bedminster, New Jersey 07921. �j RE: Site Name: SEA 4 Corners, Location Code: 102484, Contract No.: 79134, Site Address: 26800 Maple valley Black Diamond 1111,0_1111 Road SE, Maple valley, WA 98038. City of Kent is included as Additional Insured with respect to the General Liability policy. Where permitted by law, the Named Insured parties listed herein waive all rights against the Certificate Holder and each Additional Insured party listed herein for recovery of damages to the extent these damages are covered by the above-referenced General Liability and Automobile Liability policies, and, as further limited by written contract between the parties. W 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. City Of Kent AUTHORIZED REPRESENTATIVE �} Attn: City Clerk 220 Fourth Avenue Kent WA 98403 USA tXXOTii cf�iLGiae1? e/ - ©1988-2015 ACORD CORPORATION.All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD AGENCY CUSTOMER ID: 570000027366 LOC#: ARo ADDITIONAL REMARKS SCHEDULE Page _ of _ AGENCY NAMEDINSURED Aon Risk Services Northeast, Inc. Verizon Communications Inc. POLICY NUMBER See Certificate Number: 570076856042 CARRIER NAIC CODE See Certificate Number: 570076856042 EFFECTIVE DATE: ADDITIONAL REMARKS THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, FORM NUMBER: ACORD 25 FORM TITLE: Certificate of Liability Insurance INSURER(S)AFFORDING COVERAGE NAIC # INSURER INSURER INSURER INSURER ADDITIONAL POLICIES if a policy below does not include limit information,refer to the corresponding policy on the ACORD certificate form for policy limits. POLICY POLICY LTR TYPE OF INSURANCE INSDADDL WVDSUBR POLICYNUMBER EFFECTIVE EXPIRATION LIMITS LTR INSD WVD DATE DATE (MM/DD/YYYY) (MM/DD/YYYY AUTOMOBILE LIABILITY A CA 299-19-16 06/30/2019 06/30/2020 NH - Primary A CA 299-19-17 06/30/2019 06/30/2020 NH - EXcess ACORD 101(2008/01) ©2008 ACORD CORPORATION.All rights reserved. The ACORD name and logo are registered marks of ACORD POLICY NUMBER: GL 641-22-51 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 Any person or organization whom you become Per the contract or agreement. obligated to include as an additional insured as a result of any contract or agreement you have entered into. 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 that which you are required by the contract include as an additional insured the person(s) or or agreement to provide for such additional organization(s) shown in the Schedule, but only insured. with respect to liability for "bodily injury", B. With respect to the insurance afforded to these "property damage" or "personal and advertising additional insureds, the following additional injury" caused, in whole or in part, by: exclusions apply: 1. Your acts or omissions; or This insurance does not apply to "bodily injury" 2. The acts or omissions of those acting on or "property damage" occurring after: your behalf; 1. All work, including materials, parts or in the performance of your ongoing operations equipment furnished in connection with such for the additional insured(s) at the location(s) work, on the project (other than service, designated above. maintenance or repairs) to be performed by or on behalf of the additional insured(s) at However: the location of the covered operations has 1. The insurance afforded to such additional been completed; or insured only applies to the extent permitted 2. That portion of "your work" out of which by law; and the injury or damage arises has been put to 2. If coverage provided to the additional its intended use by any person or insured is required by a contract or organization other than another contractor or agreement, the insurance afforded to such subcontractor engaged in performing additional insured will not be broader than operations for a principal as a part of the same project. CG 20 10 04 13 0 Insurance Services Office, Inc.,2012 Page 1 of 2 ❑ C. With respect to the insurance afforded to these 2. Available under the applicable Limits of additional insureds, the following is added to Insurance shown in the Declarations; Section III - Limits Of Insurance: If coverage provided to the additional insured is whichever is less. required by a contract or agreement, the most This endorsement shall not increase the we will pay on behalf of the additional insured applicable Limits of Insurance shown in the is the amount of insurance: Declarations. 1. Required by the contract or agreement; or Page 2 of 2 0 Insurance Services Office, Inc.,2012 CG 20 10 04 13 0 POLICY NUMBER: GL 641-22-51 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/COMPLETEDOPERATIONS LIABILITY COVERAGE PART SCHEDULE Name Of Additional Insured Person(s) Location And Description Of Completed Operations Or Organization(s) Any person or organization whom you become Per the contract or Agreement obligated to include as an additional insured as a result of any contract or agreement you have entered into. 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 which you are required by the contract or include as an additional insured the person(s) or agreement to provide for such additional organization(s) shown in the Schedule, but only insured. with respect to liability for "bodily injury" or B. With respect to the insurance afforded to these "property damage" caused, in whole or in part, additional insureds, the following is added to by "your work" at the location designated and Section III - Limits Of Insurance: described in the Schedule of this endorsement If coverage provided to the additional insured is performed for that additional insured and required by a contract or agreement, the most included in the "products-completed operations we will pay on behalf of the additional insured hazard". is the amount of insurance: However: 1. Required by the contract or agreement; or 1. The insurance afforded to such additional 2. Available under the applicable Limits of Insu- insured only applies to the extent permitted rance shown in the Declarations; by law; and 2. If coverage provided to the additional whichever is less. insured is required by a contract or agree- This endorsement shall not increase the appli- ment, the insurance afforded to such addi- cable Limits of Insurance shown in the Decla- tional insured will not be broader than that rations. CG 20 37 04 13 0 Insurance Services Office, Inc., 2012 Page 1 of 1 ❑