Loading...
HomeMy WebLinkAboutPW17-414 - Insurance Certificate - Zayo Group, LLC - Liability Coverage - 08/01/2019 Page 1 of 1 707/25/2019 E(MM/DDNYYY) 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 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 Willis of Colorado, Inc. NAME: PHONE c/o 26 Century Blvd Ar x1: 1-877-945-7378 �C No:- Nashville, TN 372305191 USA ,-888-467-2378 P.O. Box 305191 E-MAIL AD DRESS_certificates@willis.com —'- ----- INSURER(S)AFFORDING COVERAGE NAIC Ji INSURED INSURER A: Great Northern Insurance Company 20303 Zayo Group, LLC _INSURER B: Federal Insurance company 1 20281 1805 29th Street, Suite 2050 INSURER C: Sentry casualty Company 28460 Boulder, CO 80301 USA — -- INSURER D: INSURER E: INSURER F COVERAGES CERTIFICATE NUMBER:W12114171 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 ISSUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR .... - - 'ADDL SUBR._._.__._..._.�..-. .,_._. LT R TYPE OF INSURANCE POLICYEFF POIiCYEXP POLICYNUMBER MM/DD%YYYY MM/DD/YYYY LIMITS X COMMERCIAL GENERALLIABILITY EACH OCCURRENCE $ 11000,000 CLAIMS-MADE X OCCUR DA PREMISES{Ea,occurrence I$ 1 000,000 .._t__.__i _. ._.......- A j N40 EXP(Any one person) 1$ 10,000 II j 3604-53-52 08/01/2019 08/01/2020. PERSONAL 8 ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 POLICY -X PRO LOC .-__.___-.__ _._ PRODUCTS-COMP+OPAGG $ 2,000,000 OTHER: AUTOMOBILE LIABILITY $ CM-E1NE SSINGLE LIMIT $ 1,000,000 BODILY X ANY AUTO � accldenCZ_�.___ t NJURY(Per person) G$ B OWNED I-- SCHEDULED -� AUTOS ONLY I—J AUTOS 7359-90-85 08/01/2019 08/01/2020 BODILY INJURY(Per accident) $ HIRED I NON-OWNED + — AUTOS ONLY AUTOS ONLv j PeOYaPERT DAMAGE $ - $ X: UMBRELLA LIAB X' B E�OCCUR EACH OCCURRENCE i$ 51000,00 0 EXCESS LIAB ICLAIMS-MADE I 7989-77-47 08/01/2019108/01/2020 — RETENTION�S AGGREGATE $ 5,000,000 DED ' X 10,000 ---- --- -- _ t WORKERS COMPENSATION PEI AND ROPRIFEMPLOYERS' PARTLIABILITY Y N g0-20463-01 O1/OS/2019 X 5-------- ER C ANYPROPRIETORTARTNERiE�ECUTIVE No '.NIA I i 1,000,000 (Manila cry In NEREXCLUDED. E.L.EACH ACCIDENT (Mandatory in NH) OS/01/2020 - $---- _",_ I yes,describe under E.L.DISEASE EA EMPLOYEE $ 1,000,000 DESCRIPTION OF OPERATIONS below - E.L.DISEASE-POLICY LIMIT 1$ 1,000,000 C 'Workers Compensation 90-20463-02 01/01/2 I 019 01/01/2020 E.L. Each Accident $1,000,000 li Employers Liability ! E.L.Disease-Each Emp $1,000,000 I Per Statute E.L.Disease-Pol Limit$1,000,000 DESCRIPTION OF OPERATIONS/LOCATIONS!VEHICLES (ACORD 101.Additional Remarks Schedule,may be attached if more space is required) Certificate Holder is named as an Additional Insured as respects the ongoing operations of the Named Insured with respects to General and Auto Liability coverage as required by written and signed contract subject to policy terms, conditions, limits and exclusions. 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 220 Fourth Ave S Kent, WA 98032 Aeolo / n 1988-2016 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD sR ID: 18291220 BATCH 1297890 2 of 3 5173 ar Page 1 of 1 ,ac cafrr� CERTIFICATE OF LIABILITY INSURANCE °ATE`MM°°'YYYY) 07/25/2019 FTHIS 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). PRODUCER CONTACT Willis of Colorado, Inc. _NAME; ___ _ PHONE c/o 26 Century Blvd Nn Ext: 1-877-945-7378 A/C.NI: 1-888-467-2378 P.O. Box 305191 E-MAIL Nashville, TN 372305191 USA ADDRESS: certificates@willia.com -- INSURER S AFFORDING COVERAGE NAIC# __INSURED INSURER A: Great Northern Insurance Company 20303 zayo Group, LLC INSURER B Federal Insurance company ompany 20281 1805 29th Street, Suite 2050 INSURERC: sentry Casualty Company 28460 Boulder, CO 80301 USA INSURER D: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER:W12114170 REVISION NUMBER; THIS IS TO CERTIFY' 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. LTR TYPEOFINSURANCE AbOtJ�jlytl r '-POLICY EFF POIKDyY UNITS POLICY NUMBER MM!DD,YYY MMiD X COMMERCIAL GENERAL LIABILITY $PR CH OCCURRENCE $ 1,000,000 A � ... CLAIMS-MADE XJ OCCUR E6-- EMISES,�Ea occurrence $ 1,000,000 i MED EXP(Any one person) $ 10,000 3604-53-52 08/01/2019 08/01/2020 I PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: POLICY X JECOT LOC GENERAL AGGREGATE _ $ 2,000,000 PRODUCTS-COMPIOPAGO $ 2,000,000 __P,OTHER: $ AUTOMOBILE LIABILITY I COMBINED- INGLE LIMIT $ 1,000,000 a accident X ANY AUTO E BODILY INJURY(Per B I SCHEDULED ; pen) $ 359-90-85EE AT8 AUTOS 08/01/2019 08/01/2020 BODILY INJURYiPeraccident), $ HIRED NON-OWNED PROPERTYDAMAGE AUTOS ONLY AUTOS ONLY Pe accident) _ $ � B X UMBRELtAL1AB X OCCUR EACH OCCURRENCE $ 5,000,000 EXCESS UAB L_CLAIMS-MADE 7989-77-47 08/01/2019 08/01/202011 AGGREGATE $ 5,000,000 — _ DED X RETENTION$ 10,000 WORKERS COMPENSATION AND EMPLOYERS'LIABILITY Y!N X STATUTE ER I C i ANYPROPRIETOR!PARTNERIEXECUTIVE OFFICER/MEMBEREXCLUDEO? No NIA EL EACH ACCIDENT $ 1,000,000 (Mandatory In NH) 90-20463-01 01/OS/2019 01/O1/2020 r II yes describe under E.L.DISEASE,EA EMPLOYEE $ 1,000,000 DESCRIPTION OF OPERATIONS bebw I ' E.L.DISEASE•POLICY LIMIT $ 1,000,000 C 'Workers compensation - - - -- ----. _ 90-20463-02 01/01/2019 01/01/2020 E.L. Each Accident $1,000,000 6 Employers Liability E.L.Disease-Each 8mp $1,000,000 ,Per Statute IE.L.Disease-Pol Limi $1,000,000 DESCRIPTION OF OPERATIONS!LOCATIONS!VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached If more space is required) Additional Named Insured Includes: AboveNet Communications, Inc, The City of Kent, its officers, officials, employees, agents and assigns are recognized as an Additional Insured under General, Auto and Umbrella Liability but solely as respects liability arising from the Named Insured's operations and/or work performed by the Named Insured, ATIMA.. This coverage shall apply separately to each insured. This insurance shall be primary. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. City of Kent 220 Fourth Avenue South AUTHORIZED REPRESENTATIVE Attn: City Clerk Kent, WA 98403 ©1988-2016 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD SR ID: 18291220 BATCH: 1297890 2 of 2 5176 M, Page 1 of 1 CERTIFICATE OF LIABILITY INSURANCE DATE(MM.!DD,'YYYY) 07/25/2019 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT Willis of Colorado, Inc. NAME: c/o 26 Century Blvd PHONE 1-877-945-737$ A! Ex P.O. Box 305191 A!C N 1-888-467-2378 Nashville, TN 372305191 USA ADORL S: certificates@aillis.com INSURER AFFORDING COVERAGE NAIC INSU14ERA: Great Northern Insurance company INSURED 20303 _..._. _ zayo Group, LLc INSURE RB: Federal Insurance company 20281 1805 29th Street, suite 2050 -INSURE Ic: Sentry Casualty Company 28460 Boulder, CO 80301 USA INSURER D: INSURER E:_ INSURER F: COVERAGES CERTIFICATE NUMBER:W12114172 RTIFY THAT THE POLICIES OF INSURANCEREVISION NUMBER: THIS IS TO CE 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. tNSR `____.. .v. ....-...,..__...-..._,___..,.... -ADDL SUBR: _ .... _._ LTR TYPE OFINSURANCE POLICY Ems- POLICY NUMBER MMrDDrYY INAAD Y� i LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 11000,000 CLAIMS-MADE U OCCUR PREMISES Ea occurrenoeL_ $ 1,000,000 I MED EXP(Anyone person) $ 10,000 3604-53-52 08/01/201908/01/2020' PERSONAL&ADV INJURY $ 1,000,000 GENT AGGREGATE LIMIT APPLIES PER: I GENERAL AGGREGATE $ 2,000,000 POLICY JECT LOC PRO. I PRODUCTS-COMP/OP AGG $ 2,000,000 OTHER: AUTOMOBILE LIABILITY COMBINED SINGL L MIT X ANY AUTO Ea accident E $ 1,000,000 s OWNED BODILY INJURY(Per person) $ SCHEDULED 7359-90-85 08/01/2019 08/O1/20201 Per AUTOS ONLY AUTOS BODILY INJURY(Par accident) $ HIRED NON-OWNED PROPERTY DAMAGE AUTOS ONLY AUTOS ONLY i $ 8 nt X UMBRELLA LIAR X OCCUR EACH OCCURRENCE $ 5,000,000 DEDES XtARETENi10N$ 08/O1/2020 CLAIMS-MADE I 7989-77-47 08/01/2019 10,000 AGGREGATE $ 51000,000 WORKERS COMPENSATION ; $ - AND EMPLOYERS'LIABILITY IN X STATUTE C ANYPROP(Mandatory OFFICER/MEMBER EXCLUDED? Y❑ I I 90-20463-01 01/01/2019 ..H) E_L.EACH ACCIDENT $ 1,000 000 iOFFICER7MEMBEREXCLUDEO? No NlA I Dl/O1/202D E.L.DISEASE-EA EMPLOYEE II qes,describe under ;$ 1,000,000 DESCRIPTION OF OPERATIONS below C workers Compeasati -- E.L.DISEASE•POLICY LIMIT $ 1,000,000 oa- __ ..i�-- - 90-20463-02 �Oi/Qi/301 #94/2820!fix:3ach�[cZtdli ST, s Eagrloyers Liability I I ' Per Statute 4.L.Disease-Each Emp'$1,000,000 'E.L.Disease-Pol Limit$1,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space is required) CITY OF KENT IS INCLUDED AS ADDITIONAL INSURED UNDER GENERAL LIABILITY AS REQUIRED BY WRITTEN CONTRACT, SUBJECT TO POLICY TERMS, CONDITIONS & EXCLUSIONS, WITH THE NAMED INSURED. RE: FRANCHISE/PERMITS. 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 220 4th Avenue, S Kent, WA 98032 j 7 OO 1988-2016 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD SA ID: 18291220 BATCH: 129.7890 3 of 3 5173 Page 1 of 2 DATE(MM/DD/YYYY) AC4C>RV CERTIFICATE OF LIABILITY INSURANCE 09/30/2019 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 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 NAME: Willis of Colorado, Inc. c/o 26 Century Blvd PHONE 1-677-945-7378 FAX 1-888-467-2378 AIC.No Extl: 'I (AIC,No): P.O. Box 305191 A DRESS: certificates@willis.com Nashville, TN 372305191 USA INSURERS AFFORDING COVERAGE NAIC# INSURERA: Great Northern Insurance Company 20303 INSURED INSURERB: Federal Insurance Company 20281 2ayo Group, LLC 1805 29th Street, Suite 2050 INSURER C: sentry Casualty Company 28460 Boulder, CO 80301 INSURER D INSURER E: INSURER F COVERAGES CERTIFICATE NUMBER:W13198732 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. INSR ADDLISUBR POLICY EFF POLICY EXP LTR TYPE OF INSURANCE IN POLICY NUMBER MM/DD MM/DD LIMITS X ' COMMERCIAL GENERAL LIABILITY !I EACH OCCURRENCE� -__ � S 1,000,000 — 1,000,000 DAMAGE TO RENTED CLAIMS-MADE X 'I OCCUR �, PREMISES Ea occurrence) ' $ A .I III MED EXP(Any one person) $ 10,000 Y Y 3604-53-52 �II08/01/2019 08/01/2020i PERSONAL&ADVINJURY ' $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 �I POLICY n JE� '�_ _ LOC PRODUCTS-COMP/OP AGG $ - - 2,000,000 I OTHER: S AUTOMOBILE LIABILITY 1 COMBINED SINGLE LIMIT $ 1,000,OGC Ea accident X ANY AUTO BODILY INJURY(Per person) $ - H I� 1 OWNED SCHEDULED Y 7359-90-85 08/01/2019'.08/01/2020, BODILY INJURY(Per accident) $ I AUTOS ONLY AUTOS HIRED NON-OWNED I PROPERTY DAMAGE AUTOS ONLY AUTOS ONLY I (Per accident) I�! UMBRELLA LIAB X OCCUR '. EACH OCCURRENCE $ 5,000,000 B X — — ! EXCESSLIAB CLAIMS-MADE Y 7989-77-47 '08/01/2019�08/01/20201AGGREGATE 'I$ 5,000,000 I DED I X I RETENTION$ 10,000 I WORKERS COMPENSATION '.. : X PER OTH- AND EMPLOYERS'LIABILITY . STATUTE ER _ --{{ C ANYPROPRIETOR/PARTNER/EXECUTIVE Y/N E.L.EACH ACCIDENT $ 1,000,00:11 i OFFICERIMEMBER EXCLUDED? N0 NIA 90-20463-01 101/01/2019,01/01/2020 1 ---— n (Mandatory in NH) j E.L.DISEASE-EA EMPLOYEE' $ j If yes,describe under 1,000,000 _ DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ C T'lorke_"s Compensation 9�?- 04£:.-02 01i0112019 0'_/0i!2C201E.L. Each Accident L$1,000,0:0 - --- 1;6 Employers Liability E.L.Disease-Each Emp l,$1,000,000 IPer Statute IE.L.Disease-Pol Limit$1,000,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) SEE ATTACHED 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 Rent AUTHORIZED REPRESENTATIVE Attn: City Clerk 220 Fourth Avenue South Kent, WA 98403 ©1988-2016 ACORD CORPORATION. All rights reserved. ACORD 25(2016103) The ACORD name and logo are registered marks of ACORD SR ID: 18606346 - 1389931 AGENCY CUSTOMER ID: LOC#: A�® ADDITIONAL REMARKS SCHEDULE Page 2 Of 2 AGENCY NAMEDINSURED Willis of Colorado, Inc. Zayo Group, LLC 1805 29th Street, Suite 2050 POLICY NUMBER Boulder, CO 80301 See Page 1 CARRIER _ NAIC CODE See Page 1 See Page 1 1 EFFECTIVE DATE: See Page 1 ADDITIONAL REMARKS THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, FORM NUMBER: 25 FORM TITLE: Certificate of Liability Insurance The City, its officers, officials, boards, commissions, employees, and agents are included as Additional Insureds as respects to General Liability and Auto Liability. General Liability and Auto Liability policies shall be Primary and Non-contributory with any other insurance in force for or which may be purchased by Additional Insureds. Waiver of Subrogation applies in favor of Additional Insureds with respects to General Liability. i Umbrella/Excess Follows Form. INSURER AFFORDING COVERAGE: Great Northern Insurance Company NAIC#: 20303 POLICY NUMBER: 3604-53-52 EFF DATE: 08/01/2019 EXP DATE: 08/01/2020 TYPE OF INSURANCE: LIMIT DESCRIPTION: LIMIT AMOUNT: Stop Gap Coverage Aggregate $1,000,000 North Dakota, Ohio, Washington, Bodily Inj - Accident $1,000,000 S Wyoming Bodily Inj - Disease $1,000,000 i� k-- �i f ACORD 101 (2008/01) ©2008 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD SR ID: 18606346 BATCH: 1389931 CERT: W13198732 Liability Insurance Endorsement Poky Period August 1,2019 to August 1,2020 Effective Date August 1, 2019 Pocky Number 3604-53-52 DEN Insured Zayo Group LLC Name of Company Great Northern Insurance Company Date Issued August 1, 2019 This Endorsement applies to the following forms: GENERAL LIABILITY Under Who Is An Insured,the following provision is added Who Is An Insured A Mional Insured- Persons or organizations shown in the Schedule are insureds;but they are insureds only if you are Scheduled Person obligated pursuant to a contract or agreement to provide them with such insurance as is afforded by Or Organization this policy. However,the person or organization is an insured only: • if and then only to the extent the person or organization is described in the Schedule; • to the extent such contract or agreement requires the person or organization to be afforded status as an insured; • for activities that did not occur,in whole or in part,before the execution of the contract or agreement;and • - %,ith respect to damages,loss,cost or expense for injury or da rage to whi-ch this ins'yr.= - applies. No person or organization is an insured under this provision: • that is more specifically identified under any other provision of the Who Is An Insured section(regardless of any limitation applicable thereto). • with respect to any assumption of liability(of another person or organization)by them in a contract or agreement.This limitation does not apply to the liability for damages,loss,cost or expense for injury or damage,to which this insurance applies,that the person or organization would have in the absence of such contract or agreement. Liability insurance Addttionai hewed-Sdwduled Peraw or Orgarm Von onnd wed Form 806a-22367(Rw 5,M Erxkvvam9nt Page } CHUBS' Liability Endorsement (continued) Under Conditions,the following provision is added to the condition titled Other Insurance. Conditions Other insurance— If you are obligated,pursuant to a contract or agreement,to provide the person or organization Primary, Noncontributory shown in the Schedule with primary insurance such as is afforded by this policy,then in such case Insurance—Scheduled this insurance is primary and we will not seek contribution from insurance available to such person Person Or Organization or organization. Schedule Persons or organizations that you are obligated,pursuant to a contract or agreement,to provide with such insurance as is afforded by this policy. All other terms and conditions remain unchanged Authorized Representa6ve Liability Insurance Add9ba l Insured-Sd*duAed Permian Or Orgar&a&m Aw page Fom 7(Rev."7) Endarserrmat page 2