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HomeMy WebLinkAboutCAG2021-049 - Insurance Certificate - Mercy Housing Northwest - Liability Coverage - 07/01/2021SHOULD 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-MAIL ADDRESS: 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 ER OTH- STATUTE PER LIMITS(MM/DD/YYYY) POLICY EXP (MM/DD/YYYY) POLICY EFF POLICY NUMBERTYPE OF INSURANCELTR INSR 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) © 1988-2015 ACORD CORPORATION. All rights reserved. CERTIFICATE HOLDER The ACORD name and logo are registered marks of ACORD HIRED AUTOS ONLY Greenwood Village, CO 80111 1,000,000B B 07/01/21 07/01/22 X City of Kent NREP Certs Attn: Development Engineering Kent,, WA 98032 See Attached TRAVELERS PROP CAS CO OF AMER LEXINGTON INS CO 1,000,000 [Greenwood Village - Branch ID 15327] 100,000 Edgewood Partners Insurance Center (EPIC) 220 4th Avenue South 1-303-481-7821 1,000,000 Mercy Housing, Inc. TJCAP9F337796TIL21 2,000,000 X 2,000,000 07/01/21 8101 E. Prentice Ave., Suite 410 X X (855) 228-1425 1600 Broadway, Suite 2000 07/01/22 07/01/22 07/06/2021 Excluded X 1,000,000 UB1N3971392151K UB2N1751862151R 0 caitlinmccann See Attached 07/01/21 07/01/21 08077850 X 25,000,000 $10,000 SIR X concerned. 1,000,000 as the work obligations and activities performed by the Owner/Developer and authorized by the City of Kent permit are officials, its officers, agents, employees, volunteers and representatives are listed as Additional Insureds, insofar RE: Appian Way Mercy, LLC - 25818 26th Place South, Kent, WA 98032. The City of Kent, its elected and/or appointed X 07/01/22 36056 25674 19437 N Denver, CO 80202 A 07/01/22 (303) 481-7821 C USA 62652317 62652317 0423 B 07/01/21 NREPCerts@epicbrokers.com 1,000,000 25,000,000 SUPP (10/00) SUPPLEMENT TO CERTIFICATE OF INSURANCE DATE NAME OF INSURED: Mercy Housing, Inc. 07/06/2021 This page is left intentionally blank. SUPP (10/00) SUPPLEMENT TO CERTIFICATE OF INSURANCE DATE NAME OF INSURED: Mercy Housing, Inc. Limits of Liability: $25,000,000 Any One Occurrence Policy Number: WTS40002505318 Carrier: Lloyd's of London (Lloyd's Syndicate 4000) Terrorism Liability: Total Limit: $25,000,000 Each Occurrence/Aggregate Participation: $5,000,000 Each Occurrence/Aggregate xs of $20,000,000 Each Occurrence/Aggregate Policy Number: 93652713 Insured: Federal Insurance Co. Participation: $5,000,000 Each Occurrence/Aggregate xs of $15,000,000 Each Occurrence/Aggregate Policy Number: 08303275 Insured: Lexington Insurance Co. Participation: $5,000,000 Each Occurrence/Aggregate xs of $10,000,000 Each Occurrence/Aggregate Policy Number: AEC097192502 Insured: Steadfast Insurance Co. Participation: $5,000,000 Each Occurrence/Aggregate xs of $5,000,000 Each Occurrence/Aggregate Policy Number: 01BXLP000309550 Insured: Ategrity Specialty Insurance Co. Participation: $3,000,000 Each Occurrence/Aggregate xs of $2,000,000 Each Occurrence/Aggregate Policy Number: 03129657 Insured: Allied World Insurance Co. Participation: $2,000,000 Each Occurrence/Aggregate Policy Number: 20000000177 Insurer: Mercer Insurance Co. Schedule of Participation - Excess Liability 07/06/2021