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HomeMy WebLinkAboutCAG2020-129 - Insurance Certificate - New Cingular Wireless PCS, LLC - 06/01/2020-06/01/2021 Coverage with Increased Workers Comp. - 05/20/2020SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. INSURER(S) AFFORDING COVERAGE INSURER F : INSURER E : INSURER D : INSURER C : INSURER B : INSURER A : NAIC # NAME:CONTACT (A/C, No):FAX E-MAILADDRESS: PRODUCER (A/C, No, Ext):PHONE INSURED REVISION NUMBER:CERTIFICATE NUMBER:COVERAGES 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). 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. OTHER: (Per accident) (Ea accident) $ $ N / A SUBR WVD ADDL INSD 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. $ $ $ $PROPERTY DAMAGE BODILY INJURY (Per accident) BODILY INJURY (Per person) COMBINED SINGLE LIMIT AUTOS ONLY AUTOSAUTOS ONLY NON-OWNED SCHEDULEDOWNED ANY AUTO AUTOMOBILE LIABILITY Y / N WORKERS COMPENSATION AND EMPLOYERS' LIABILITY OFFICER/MEMBER EXCLUDED? (Mandatory in NH) DESCRIPTION OF OPERATIONS below If yes, describe under ANY PROPRIETOR/PARTNER/EXECUTIVE $ $ $ E.L. DISEASE - POLICY LIMIT E.L. DISEASE - EA EMPLOYEE E.L. EACH ACCIDENT EROTH-STATUTEPER LIMITS(MM/DD/YYYY)POLICY EXP(MM/DD/YYYY)POLICY EFFPOLICY NUMBERTYPE OF INSURANCELTRINSR DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) EXCESS LIAB UMBRELLA LIAB $EACH OCCURRENCE $AGGREGATE $ OCCUR CLAIMS-MADE DED RETENTION $ $PRODUCTS - COMP/OP AGG $GENERAL AGGREGATE $PERSONAL & ADV INJURY $MED EXP (Any one person) $EACH OCCURRENCE DAMAGE TO RENTED $PREMISES (Ea occurrence) COMMERCIAL GENERAL LIABILITY CLAIMS-MADE OCCUR GEN'L AGGREGATE LIMIT APPLIES PER: POLICY PRO-JECT LOC CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DD/YYYY) CANCELLATION AUTHORIZED REPRESENTATIVE ACORD 25 (2016/03) © 1988-2016 ACORD CORPORATION. All rights reserved. CERTIFICATE HOLDER The ACORD name and logo are registered marks of ACORD HIRED AUTOS ONLY 5,000,000 MWZY 31363620 CHI-009390211-02 5,000,000 X Dallas, TX 75202 EL Disease-Policy LimitSee Second Page of Marsh USA Inc. Attn: ATT.CertRequest@marsh.com N 06/01/2020 X06/01/2020 06/01/2021 06/01/2020 A Att.CertRequest@marsh.com MWTB 313635 20 Excess Workers' Compensation / A 10,000,000 5,000,000 5,000,000 X A X 05/20/2020 N 1,000,000 06/01/2020 1,000,000 The City, its officials, employees & volunteers is/are included as Additional Insured under the General Liability policy but only with respect to the requirements of the contract between the Certificate Holder and the Insured. Waiver of Subrogation is provided for General Liability and Automobile Liability, as required by written contract and allowable by law. This insurance is primary with respect to the interest of the Additional X Kent, WA 98032 City of Kent WA Insured and any other insurance maintained by Additional Insured is excess and non-contributory with this insurance. A CN103150778-GAW-CRT-20-21 EL Each Accident / EL Disease N/A 06/01/2021 5,000,000 06/01/2021 Employers' Liability MWZX 31363720 (MI) 5,000,000 24147 1,000,000 Y 5,000,000 06/01/2021 MWC 31363820 (AOS) 701 Market Street, Suite 1100 Marsh USA Inc. St. Louis, MO 63101 One AT&T Plaza New Cingular Wireless PCS, LLC Room 1820 208 South Akard MWXS 31363920 (OH,WA) 06/01/2020 220 Fourth Avenue South Y A US Centralized Services 06/01/2021 866-966-4664 Old Republic Insurance Company ACORD 101 (2008/01) The ACORD name and logo are registered marks of ACORD © 2008 ACORD CORPORATION. All rights reserved. THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, FORM NUMBER:FORM TITLE: ADDITIONAL REMARKS ADDITIONAL REMARKS SCHEDULE Page of AGENCY CUSTOMER ID: LOC #: AGENCY CARRIER NAIC CODE POLICY NUMBER NAMED INSURED EFFECTIVE DATE: 22 Excess Automobile Liability - MWZX 31363720 (MI) � � St. Louis OH & WA - $600,000,000 Terrorism� OH & WA - $500,000,000 (except Terrorism) � ******************************� � �� �� Self Insured Retentions � Excess Workers' Compensation -MWXS 31363920 (OH-WA) � Certificate of Liability Insurance CN103150778 Combined Single Limit - $1,000,000 � �� Marsh USA Inc.� One AT&T Plaza� New Cingular Wireless PCS, LLC� Room 1820� 208 South Akard� Dallas, TX 75202 25 Self Insured Retention - $1,000,000�