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HomeMy WebLinkAboutCAG2020-164 - Insurance Certificate - CivicPlus, Inc. - SeeClickFix Liability Coverage - 05/17/2021ApprovalOriginator:Department: Date Sent:Date Required: Authorized to Sign: Director or Designee Mayor Date of Council Approval: Grant? Yes No Type:Review/Signatures/RoutingDate Received by City Attorney: Comments: Date Routed to the Mayor’s Office: Date Routed to the City Clerk’s Office:Agreement InformationVendor Name:Category: Vendor Number:Sub-Category: Project Name: Project Details: Agreement Amount: Start Date: Basis for Selection of Contractor: Termination Date: Local Business? Yes No* Business License Verification: Yes In-Process Exempt (KCC 5.01.045) If meets requirements per KCC 3.70.100, please complete “Vendor Purchase-Local Exceptions” form on Cityspace. Notice required prior to disclosure? Yes No Contract Number: Agreement Routing Form For Approvals, Signatures and Records Management This form combines & replaces the Request for Mayor’s Signature and Contract Cover Sheet forms. (Print on pink or cherry colored paper) Visit Documents.KentWA.gov to obtain copies of all agreementsadccW22373_1_20 Budget Account Number: Budget? Yes No Dir Asst: Sup/Mgr: Dir/Dep: rev. 200821 FOR CITY OF KENT OFFICIAL USE ONLY (Optional) * Memo to Mayor must be attached Certificate of Insurance for CivicPlus, Inc SeeClickFix subscription . Page 1 of 2 - 1 ��� ACCJP► V)) CERTIFICATE OF LIABILITY INSURANCE DQTE(MMIDDNYYY) l� 05/18/2021 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 Willie Towers Watson Certificate Center NAME - Willis Willie Towers Watson Northeast, Inc PHONE 1-877-945-7378 FAX 1-888-467-2378 c/o 26 Century Blvd -N Y - AIC No: P.O. Box 305191 E-MAIL zertiPiratesQwillis . com APoR..Es�: Nashville, TN 372305191 USA INSURED CivicPlus, LLC 302 s 4th street, suite 500 Manhattan, Ks 66502 INSURERIS�AFFORDING COVERAGE _ NAIC U INSURERA: Great Northern Insurance Company 20303 INSURERS- Federal Insurance Company 20281 INSURERC: Westchester Surplus Lines Insurance Compan 10172 INSURER D : INSURER E : COVERAGES CERTIFICATE N11MAF11W20947800 R1=VICIr1N NIIIIARFR• 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. IN�RR TYPEOFINSURANCE AbbLSuBT P041CyyEFF 1 POLICcYppX POLICY NUMBER MMDO/YY Y MMDDIYY�Y LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 2,000,000 CLAIMS -MADE ! "' 1 OCCUR PREMISES (Ea occur,ence $ 2, 000, 000 A �05/17/2021 MED EXP (Any one person) $ 10,000 PERSONAL & ADV INJURY $ 1,000,000 3602-53-12 05/17/2022 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: IRRp FI 1 POLICY lECT LOC PRODUCTS - COMP/OP AGG $ 2,000,000 Is OTHER: AUTOMOBILE LIABILITY COMBINED SING E LTMFr $ -(Ea 40A60nl) _ J ANY AUTO BODILY INJURY (Per person) $ OWNED SCHEDULED AUTOS ONLY AUTOS BODILY INJURY (Per accident) $ HIRED NON -OWNED HQPERTY AMAGE $ AUTOS ONLY AUTOS ONLY ..Pbr,�cxWeaiig _ UMBRELLALIAB OCCUR EACHOCCURRENCE $ AGGREGATE $ EXCESS LAB CLAIMS -MADE DIED I I RETENTION$ $ WORKERS COMPENSATION X - TAT TE ER AND EMPLOYERS' LIABILITY YIN E.L. EACH ACCIDENT a ANYPROPRIETOR/PARTNER/EXECUTIVE $ 1,000,000 OFFICER/MEMBEREXCLUDED? (Mandatory In NH) NIA ( 22 ) 7174-92-49 05/L7/2021 05/17/2022 ' E.L. DISEASE - EA EMPLOYER $ 1,000,000 I II yes, describe under E.L. DISEASE - POLICY LIMIT $ 1, 000, 000 DESCRIPTION OF OPERATIONS below C Tech E60 V15611984 002 04/30/2021 04/30/2022 Each Claim/Aggregate $1,000,000 Cyber Liability Each Claim/Aggregate $2,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached If more space Is required) Division Branch: CivicService - Project Location:Kent, WA City of Kent, WA as Additional Insured Coverage shall apply separately to each insured against whom claim is made or suit is brought, except with respects to the limits of the insurer's liability. General Liability policy shall be Primary with any other insurance in force for or which may be purchased by %,r-n I-IrILjA I C "LILUCFI C;ANC:tLLA I IVN SHOULD ANY OF THE ABOVE DESCRIBED POLJCIES BE CANCELLED BEFORE THE EXaIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Kent, Washington AUTHORIZED REPRESENTATIVE Attn: Brian Rambonga 220 Fourth Avenue South L( Kent, WA 98032 01988-2016 ACORD CORPORATION. All rights reserved. ACORD 25 (2016103) The ACORD name and logo are registered marks of ACORD 9A ID: 21110780 BaTCH; 2098802 2 of 2 4073 AGENCY CUSTOMER ID: LOC #: annITIONOI RRMARKS SCHEDULE AGENCY Willis Towers Watson Northeast, Inc. POLICY NUMBER See Page 1 CARRIER See Page 1 LnniTIC NAL RERAARKS NAMED INSURED CivicPlus, LLC 302 S 4th Street, Suite 500 Manhattan, KS 66502 NAIC CODE See Page 1 EFFECTIVE DATE: See Page 1 THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, FORM NUMBER: 25 FORM TITLE: Certificate of Liability Insurance Additional Insured.. Page 2 of 2 ACORD 101 (2008/01) © 2008 ACORD CORPORATION. All rights reserVeo, The ACORD name and logo are registered marks of ACORD SR iD: 21110780 BATCH: 2098802 CERT: W20947800