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HomeMy WebLinkAboutCAG2023-137 - Insurance Certificate - Mercy Housing Northwest - Liability Coverage - 07/01/2023 C' CERTIFICATE OF LIABILITY INSURANCE 07/14/2023Yv) 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 1-303-481-7821 CONTACT NAME: NREP Certs Edgewood Partners Insurance Center (EPIC) PHONE FAX [Greenwood Village - Branch ID 15327] DIV# 513 AIC No Ext: (303) 481-7821 A/C No; (855) 228-1425 E-MAIL icbrokers.com 8101 E. Prentice Ave. , Suite 410 ADDRESS: NREPCerts@epicbrokers.com INSURER(S)AFFORDING COVERAGE NAIC# Greenwood Village, CO 80111 INSURER A: LEXINGTON INS CO 19437 INSURED INSURER B: TRAVELERS PROP CAS CO OF AMER 25674 Mercy Housing, Inc. INSURER CSee Attached 36056 1600 Broadway, Suite 2000 INSURERD: INSURER E: Denver, CO 80202 INSURERF: COVERAGES CERTIFICATE NUMBER: 69288115 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 TYPE OF INSURANCE ADDL SUBR POLICY EFF POLICY EXP LIMITS LTR INSD WVD POLICY NUMBER MM/DD/YYYY MM/DD/YYYY A X COMMERCIAL GENERAL LIABILITY 080877850 07/01/23 07/01/24 EACH OCCURRENCE $ 1,000,000 F__� DAMAGE TO RENTED CLAIMS-MADE OCCUR PREMISES Ea occurrence) ccurrrence $ 100,000 00,000 X $10,000 SIR MED EXP(Any one person) $ Excluded PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 POLICY PRO X❑ JECT LOC PRODUCTS-COMP/OPAGG $ 2,000,000 OTHER: $ B AUTOMOBILE LIABILITY TJCAP9F3377961ND23 07/01/23 07/01/24 COMBINED SINGLE LIMIT $ 1,000,000 Ea accident X ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS HIRED NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY AUTOS ONLY Per accident L $ C UMBRELLA LIAB X OCCUR See Attached 07/01/23 07/01/24 EACH OCCURRENCE $ 25,000,000 X EXCESS LIAB CLAIMS-MADE AGGREGATE $ 25,000,000 DED RETENTION$ 0 $ ER B WORKERS COMPENSATION UB1N1751862351R 07/01/23 07/01/24 X STATUTE ERH AND EMPLOYERS'LIABILITY B ANYPROPRIETOR/PARTNER/EXECUTIVE � N/A UB1N3971392351K 07/01/23 07/01/24 E.L.EACH ACCIDENT $ 1,000,000 OFFICER/M EMBER EXCLUDED? (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 1,000,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 1,000,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) RE: Appian Way Mercy, LLC - 25818 26th Place South, Kent, WA 98032. The City of Kent, its elected and/or appointed officials, its officers, agents, employees, volunteers and representatives are listed as Additional Insureds, insofar as the work obligations and activities performed by the Owner/Developer and authorized by the City of Kent permit are concerned. CERTIFICATE HOLDER CANCELLATION 0423 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE City of Kent THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Attn: Development Engineering 220 4th Avenue South AUTHORIZED REPRESENTATIVE Kent_ WA 98032 USA ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD scapone 69288115 DATE SUPPLEMENT TO CERTIFICATE OF INSURANCE 07/14/2023 NAME OF INSURED: Mercy Housing, Inc. This page is left intentionally blank. SUPP(10/00) SUPPLEMENT TO CERTIFICATE OF INSURANCE Schedule of Participation — Excess Liability Insurer: AXIS Surplus Insurance Company Policy Number: P001 00118541901 Participation: $2,000,000 Each Occurrence/Aggregate Insured: Fair American Select Insurance Company Policy Number: CSX800028700 Participation: $3,000,000 Each Occurrence/Aggregate xs of$2,000,000 Each Occurrence/Aggregate Insured: Ategrity Specialty Insurance Co. Policy Number: 01 BXLP000309552 Participation: $5,000,000 Each Occurrence/Aggregate xs of$5,000,000 Each Occurrence/Aggregate Insured: Steadfast Insurance Co. Policy Number: AEC097192504 Participation: $5,000,000 Each Occurrence/Aggregate xs of$10,000,000 Each Occurrence/Aggregate Insured: Lexington Insurance Co. Policy Number: 018303275 Participation: $5,000,000 Each Occurrence/Aggregate xs of$15,000,000 Each Occurrence/Aggregate Insured: Texas Insurance Co. Policy Number: JT123XANNO183302 Participation: $5,000,000 Each Occurrence/Aggregate xs of$20,000,000 Each Occurrence/Aggregate Total Limit: $25,000,000 Each Occurrence/Aggregate Terrorism Liability: Carrier: Lloyd's of London (Lloyd's Syndicate 4000) Policy Number: WTS400020531801 Limits of Liability: $27,000,000 Any One Occurrence ACORD 25(2016/03) Supplemental Page ENDORSEMENT # 036 This endorsement, effective 12:01 AM 07/01/2023 Forms a part of policy no.: 080877850 Issued to: MERCY HOUSING, INC. By: LEXINGTON INSURANCE COMPANY ADDITIONAL INSURED - DESIGNATED PERSON OR ORGANIZATION (Based on CG2026 04/13) This endorsement modifies insurance provided by the following: COMMERCIAL GENERAL LIABILITY POLICY SCHEDULE Name of Additional Insured Person(s) or Organization(s) Attached 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 include as an additional insured the person(s) or organization(s) shown in the Schedule, but only with respect to liability for "bodily injury", "property damage" or "personal and advertising injury" caused, in whole or in part, by your acts or omissions or the acts or omissions of those acting on your behalf: 1. In the performance of your ongoing operations; or 2. In connection with your premises owned by or rented to you. However: 1. The insurance afforded to such additional insured only applies to the extent permitted by law, and 2. If coverage provided to the additional insured is required by a contract or agreement, the insurance afforded to such additional insured will not be broader than that which you are required by the contract or agreement to provide for such additional insured. B. With respect to the insurance afforded to these additional insureds, the following is added to Section III - Limits Of Insurance: If coverage provided to the additional insured is required by a contract or agreement, the most we will pay on behalf of the additional insured is the amount of insurance: 1. Required by the contract or agreement; or Includes Copyrighted Information of the Insurance Services Page 1 of 2 Offices, Inc.,with its permission. All Rights Reserved. 2. Available under the applicable Limits of Insurance shown in the Declarations; whichever is less. This endorsement shall not increase the applicable Limits of Insurance shown in the Declarations All other terms and conditions of the policy remain the same. Authorized Representative Includes Copyrighted Information of the Insurance Services Page 2 of 2 Offices, Inc.,with its permission. All Rights Reserved. Mercy Housing, Inc. Additional Insured -Designated Person or Organization CG 20 26 07 04 City of Kent 220 Fourth Avenue South Kent,WA 98032