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HomeMy WebLinkAboutCAG2023-542 - Insurance Certificate - P&D Tree Service - Liability Coverage - 11/09/2023 ® /Y E(MM/DDYYY) A��� CERTIFICATE OF LIABILITY INSURANCE 711/6/2023 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: FirstMark Insurance Group,Inc. FA FirstMark Insurance Group,Inc. PHONE 425 582-9037 (425)608-9187 A/C,No,Ext: ( ) (A/C,No): Agent:Rob Balderas ADDRESS: commecial@firstmarkinsurance.com 12918 Mukilteo Speedway Ste C-23 PMB 603 INSURER(S)AFFORDING COVERAGE NAIC# Lynnwood, WA 98087-5125 INSURER A: ADMIRAL INSURANCE CO 24856 INSURED INSURER B: EVANSTON INS CO 35378 Combined Cutting Contractors Inc and PND Tree Service INSURER C: ASCOT SPECIALTY INSURANCE CO 45055 20311 SE 240TH ST INSURER D: INSURER E: MAPLE VALLEY WA 98038-8618 INSURER F: COVERAGES CERTIFICATE NUMBER: 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. LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER (MM/DD/YYYY) (MM/DD/YYYY) LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 UL CLAIMS-MADE OCCUR PREMISES(Ea occurrence) $ 300,000 UAIV MED EXP(Any one person) $ 5,000 A Y Y CA000040031-04 11/09/2023 11/09/2024 PERSONAL&ADVINJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 POLICY Fx_1 ECT LOC PRODUCTS-COMP/OP AGG $ 2,000,000 OTHER: $ AUTOMOBILE LIABILITY (Ea accident) $ 1,000,000 ANY AUTO BODILY INJURY(Per person) $ C AU OWN TOS ONLY AUTOS ED y SCHEDULED Y Y ESAL2310000563-03 11/09/2023 11/09/2024 BODILY INJURY(Per accident) $ /� HIRED y NON-OWNED $ AUTOS ONLY /� AUTOS ONLY (Per accident) X $ UMBRELLA LAB X OCCUR EACH OCCURRENCE $ 4,000,000 B X EXCESS LIAB CLAIMS-MADE Y MKLV5EUL105412 11/09/2023 11/09/2024 AGGREGATE $ 4,000,000 DED I X RETENTION$ $0 $ WORKERS COMPENSATION STATUTE X ER WA STOP GAP AND EMPLOYERS'LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE Y/N E.L.EACH ACCIDENT $ 1,000,000 A OFFICER/MEMBER EXCLUDED? N/A CA000040031-04 11/09/2023 11/09/2024 (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) See ACORD 101 CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN City of Kent ACCORDANCE WITH THE POLICY PROVISIONS. Park Operations-Gillian Dreier-Lawrence AUTHORIZED REPRESENTATIVE 220 Fourth Avenue South 1-0ma M Wa Li Kent,WA 98032 ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD AGENCY CUSTOMER ID: _ LOC#: ACCN?"® ADDITIONAL REMARKS SCHEDULE Page 1 Of 1 AGENCY NAMED INSURED FirstMark Insurance Group, Inc. Combined Cutting Contractors Inc and PND Tree Service POLICY NUMBER EZXS3096566, ESAL221000056303,CA000040031-04 r RIER NAIC CODEANSTON INS CO 35378, EFFECTIVE DATE: ADDITIONAL REMARKS THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, FORM NUMBER: 25 FORM TITLE: Certificate Of Liability Insurance Re: Hazardous Tree Removal at Morrill Meadows Park Kent WA. City of Kent et.al is included as an Additional Insured with respect to General Liability and Auto Liability where required by written contract.Excess Liability follows form with respect to General Liability and Employer's Liability.Coverage is primary and non-contributory over any other insurance.Waiver of Subrogation applies in favor of the City of Kent et.al with respect to General Liability and Auto Liability where required by written contract.30-day written notice of cancellation applies. 10 days in the event of non-payment of premium. ACORD 101 (2008/01) ©2008 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD Policy Number: CA000040031-04 PRIMARY AND NONCONTRIBUTORY— OTHER INSURANCE CONDITION (Insurance Services Office Endorsement CG 20 01 0413) The following is added to the Other Insurance Condition and supersedes any provision to the contrary: Primary And Noncontributory Insurance This insurance is primary to and will not seek contribution from any other insurance available to an additional insured under your policy provided that: (1) The additional insured is a Named Insured under such other insurance; and (2) You have agreed in writing in a contract or agreement that this insurance would be primary and would not seek con- tribution from any other insurance available to the additional insured. WAIVER OF TRANSFER OF RIGHTS OF RECOVERY AGAINST OTHERS TO US (Insurance Services Office Endorsement CG 24 04 05 09) SCHEDULE Name Of Person Or Organization: Any person or organization, but only if the following conditions are met: (1) You have expressly agreed to the waiver in a written contract;and (2) The injury or damage first occurs subsequent to the execution of the written contract. Information required to complete this Schedule, if not shown above,will be shown in the Declarations. The following is added to Paragraph 8.Transfer Of Rights Of Recovery Against Others To Us of Section IV—Con- ditions: We waive any right of recovery we may have against the person or organization shown in the Schedule above because of payments we make for injury or damage arising out of your ongoing operations or"your work" done under a contract with that person or organization and included in the "products-completed operations hazard". This waiver applies only to the person or organization shown in the Schedule above. AD 68 93 0117 Includes copyrighted material of Insurance Services Office, Inc., Page 5 of 13 ❑ with its permission, 2009, 2012 &2013. Policy Number: CA000040031-01 CG 20 37 12 19 Policy Number:CA000040031-04 Effective Date: 11/09/2020 Effective Date: 11/09/2022 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - OWNERS, LESSEES OR CONTRACTORS - COMPLETED OPERATIONS This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE PART SCHEDULE Name Of Additional Insured Person(s) Location And Description Of Or Organization(s) Completed Operations Any person or organization that is an owner, lessee or All locations except locations where "your work" is or manager of real property or personal property for was related to a job or project involving single-family whom you work or have worked, or a contractor on dwellings, multi-family dwellings (other than rental whose behalf you work or have worked, but only if apartments in an apartment building: (a) originally coverage as an additional insured extending to "bodily constructed and at all times used for such purpose, or injury" or"property damage" included in the (b) converted from a commercial building), "products-completed operations hazard" is required condominiums,townhomes,townhouses,time-share by a written contract or written agreement that is an units, fractional-ownership units, cooperatives and/or "insured contract" and provided that the "bodily any other structure or space used or intended to be injury" or"property damage" first occurs subsequent used as a residence. to the execution of the contract or agreement. 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" or"property damage" caused, in whole or in part, by "your work" at the location designated and described in the Schedule of this endorsement performed for that additional insured and included in the "products- completed operations hazard". However: CG 20 37 12 19 © Insurance Services Office, Inc., 2018 Page 1 of 2 ❑ 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 2. Available under the applicable limits of insurance; whichever is less. This endorsement shall not increase the applicable limits of insurance. CG 20 37 12 19 © Insurance Services Office, Inc., 2018 Page 2 of 2 COMMERCIAL AUTO CA 04 49 11 16 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. CA 04 49 11 16 © Insurance Services Office, Inc., 2016 Page 1 of 1 PRIMARY AND NONCONTRIBUTORY – OTHER INSURANCE CONDITION This endorsement modifies insurance provided under the following: AUTO DEALERS COVERAGE FORM BUSINESS AUTO COVERAGE FORM MOTOR CARRIER COVERAGE FORM With respect to coverage provided by this endorsement, the provisions of the Coverage Form apply unless modified by the endorsement. A.The following is added to the Other Insurance Condition in the Business Auto Coverage Form and the – Other Insurance Primary And Excess Insurance Provisions in the Motor Carrier Coverage Form and supersedes any provision to the contrary: This Coverage Form's Covered Autos Liability Coverage is primary to and will not seek contribution from any other insurance available to an "insured" under your policy provided that: 1.Such "insured" is a Named Insured under such other insurance; and 2.You have agreed in writing in a contract or agreement that this insurance would be primary and would not seek contribution from any other insurance available to such "insured". B.The following is added to the Other Insurance Condition in the Auto Dealers Coverage Form and supersedes any provision to the contrary: This Coverage Form's Covered Autos Liability Coverage and General Liability Coverages are primary to and will not seek contribution from any other insurance available to an "insured" under your policy provided that: 1.Such "insured" is a Named Insured under such other insurance; and 2.You have agreed in writing in a contract or agreement that this insurance would be primary and would not seek contribution from any other insurance available to such "insured". Policy Number: ESAL2110000563-03 Policy Number: CA000040031-04 AD 66 2104 95 Effective Date: 11/09/2022 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. STOP GAP EMPLOYERS LIABILITY ENDORSEMENT This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART It is agreed that this policy is hereby amended as indicated. a. to"bodily injury"intentionally caused or aggravated All other terms and conditions of this policy remain un- by or at your direction,or"bodily injury"resulting changed. from an act which is determined to have been com- SECTION I COVERAGES mitted by or at your direction with the belief that an injury is substantially certain to occur; COVERAGE D.EMPLOYERS LIABILITY b. to liability assumed by you under any contract or 1.Insuring Agreement: agreement; a. We will pay those sums that you become legally obli- gated to pay as damages because of"bodily injury" c. to any obligation for which you or any carrier as caused by an accident or disease to any employee of your insurer may be held liable under any workers' yours arising out of and in the course of their employ- compensation or occupational disease law,any un- ment provided the employee is reported and declared employment compensation or disability benefits law, under a workers'compensation fund of one or more or under any similar law; of the following states: Washington,West Virginia, d. with respect to any employee employed in violation Wyoming,North Dakota,Ohio or Nevada. No other obligation or liability to pay sums or perform acts or of law with your knowledge or acquiescence or any services is covered unless explicitly provided for un- der SUPPLEMENTARY PAYMENTS--COVER- e. to any claim brought against you by or on behalf of AGES A AND B. This insurance applies only to any employee for"bodily injury" or death resulting "bodily injury"which occurs during the policy period. therefrom(1)if benefits therefore under any work- The"bodily injury"must be caused by an"occur- ers'compensation or occupational disease law are rence." The"occurrence"must take place in the"cov- accepted by or on behalf of such employee or(2) erage territory." We will have the right and duty to with respect to which your defenses have been abro- defend any"suit"seeking those damages. But: gated by reason of your failure to comply with the (1)The amount we will pay for damages is limited as provisions of any workers'compensation or occupa- described herein; tional disease law; (2)We may investigate and settle any claim or"suit" at our discretion;and f. to"bodily injury"or death resulting therefrom(1) (3) Our right and duty to defend end when we have sustained by any member of the flying crew of an used up the applicable limit of insurance in the aircraft,(2)sustained by a master or member of the payment of judgments or settlements under Cov- crew of any vessel,(3)sustained by any person sub- erages A,B or D or medical expenses under Cov- ject to the Longshoremens and Harbor Workers' erage C. Compensation Act(33 USC Sections 901-950),The b. Damages because of"bodily injury"include dam- Federal Coal Mine Health and Safety Act of 1969 ages claimed by any person or organization for care, (30 USC Sections 931-942)or The Federal Employ- loss of services or death resulting at any time from ers Liability Act(45 USC Sections 51-60),or any amendment to those laws; the"bodily injury." 2. Exclusions: g. to any claim sustained by any employee not de- This insurance does not apply to: scribed in the Insuring Agreement of this endorse- ment;or AD 66 2104 95 Page 1 of 2 ❑ h. to liability arising out of collusion,criticism,demo- 2. Bodily Injury by Disease$1,000,000 each employee,is tion,evaluation,reassignment,discipline,defama- the most we will pay for all damages because of"bod- tion,harassment,humiliation,discrimination against ily injury"by disease to any one employee. or termination of any employee,or any personnel 3. Bodily Injury by Disease$1,000,000 policy limit,is practices,policies,acts or omissions; the most we will pay for all damages covered by this i. to liability arising out of"bodily injury",disease or insurance and arising out of"bodily injury"by disease, sickness, including death at any time resulting there- regardless of the number of employees who sustain from,for past,present or future claims arising in "bodily injury"by disease. whole or in part,either directly or indirectly,out of "Bodily injury"by disease does not include disease that re- the manufacture, distribution, sale,resale,rebrand- sults directly from"bodily injury"by accident. ing,installation,repair,removal,encapsulation, 3. The General Aggregate Limit is the most we will pay abatement,replacement or handling of exposure to for the sum of- or testing for,asbestos or products containing asbes- a. Medical expenses under Coverage C;and tos whether or not the asbestos is or was at any time b. Damages under Coverage A, Coverage B and airborne as a fiber or particle contained in a product, Coverage D,except damages because of injury carried on clothing,inhaled,transmitted in any fash- and damage included in the"products-completed ion or found in any form whatsoever. operations"hazard. SUPPLEMENTARY PAYMENTS-COVERAGES A SECTION IV-COMMERCIAL GENERAL LIABILITY AND B(SECTION I)is extended to apply to coverage pro- CONDITIONS is extended to apply to coverage provided vided by this endorsement. by this endorsement. SECTION II-WHO IS AN INSURED DEFINITIONS(SECTION V-CG 00 01)(SECTION VI- You are an insured if you are an employer named in the CG 00 02)is extended to apply to coverage provided by Declaration of this policy. If that employer is a partnership, this endorsement. and if you are one of its partners,you are an insured,but The premium for this endorsement shall be computed upon only in your capacity as an employer of the partnership's the remuneration earned by such employees as are reported employees. under a workers' compensation law of the state(s)named SECTION III-LIMITS OF INSURANCE herein. Regardless of the number of(1)insureds under this policy, (2)persons who sustain"bodily injury"or(3)claims made or"suits"brought on account of"bodily injury"our liability for the coverage provided by this endorsement is limited as follows: 1. Bodily Injury by Accident$1,000,000 each accident, is the most we will pay for all damages covered by this endorsement because of"bodily injury"to one or more employees in any accident. A disease is not "bodily injury"by accident unless it results directly from"bodily injury"by accident. AD 66 21 04 95 Page 2 of 2 ❑ Policy Number: CA000040031-01 CG 20 10 12 19 Policy Number:CA000040031-04 Effective 11/09/2022 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - OWNERS, LESSEES OR CONTRACTORS - SCHEDULED PERSON OR ORGANIZATION This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Name Of Additional Insured Person(s) Location(s) Of Covered Operations Or Organization(s) Any person or organization that is an owner,lessor or All locations at which the Named Insured is perform- manager of real property or personal property on ing ongoing operations. which you are performing ongoing operations, or a contractor on whose behalf you are performing ongo- ing operations, but only if coverage as an additional insured is required by a written contract or written agreement that is an"insured contract", and provided the "bodily injury"or"property damage" first occurs, or the "personal and advertising injury"offense is first committed, subsequent to the execution of the contract or agreement. Information required to complete this Schedule, if not shown above,will be shown in the Declarations. CG 2010 12 19 © Insurance Services Office, Inc., 2018 Page 1 of 2 ❑ 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: 1. Your acts or omissions; or 2. The acts or omissions of those acting on your behalf; in the performance of your ongoing operations for the additional insured(s) at the location(s) designated above. 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 additional exclusions apply: This insurance does not apply to "bodily injury" or"property damage" occurring after: 1. All work, including materials, parts or equipment furnished in connection with such work, on the project (other than service, maintenance or repairs)to be performed by or on behalf of the additional insured(s) at the location of the covered operations has been completed; or 2. That portion of"your work" out of which the injury or damage arises has been put to its intended use by any person or organization other than another contractor or subcontractor engaged in performing operations for a principal as a part of the same project. C. 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 2. Available under the applicable limits of insurance; whichever is less. This endorsement shall not increase the applicable limits of insurance. CG 2010 12 19 © Insurance Services Office, Inc., 2018 Page 2 of 2 ❑ POLICY NUMBER:ESAL2310000563-03 COMMERCIAL AUTO CA 20 48 10 13 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. DESIGNATED INSURED FOR COVERED AUTOS LIABILITY COVERAGE This endorsement modifies insurance provided under the following: AUTO DEALERS COVERAGE FORM BUSINESS AUTO COVERAGE FORM MOTOR CARRIER COVERAGE FORM With respect to coverage provided by this endorsement, the provisions of the Coverage Form apply unless modified by this endorsement. This endorsement identifies person(s) or organization(s) who are "insureds" for Covered Autos Liability Coverage under the Who Is An Insured provision of the Coverage Form. This endorsement does not alter coverage provided in the Coverage Form. This endorsement changes the policy effective on the inception date of the policy unless another date is indicated below. Named Insured: «insured»Combined Cutting Contractors Inc and PND Tree Service Endorsement Effective Date: «Short(effective)» 11/09/2023 SCHEDULE Name Of Person(s) Or Organization(s): Any person(s) or organization(s) for whom you are performing operations when you and such person or organization have agreed in writing in a contract or agreement that such person or organization be added as an additional insured on your policy. The written contract or agreement must be signed by both parties prior to the "accident" or the"loss." Information required to complete this Schedule, if not shown above, will be shown in the Declarations. Each person or organization shown in the Schedule is an "insured" for Covered Autos Liability Coverage, but only to the extent that person or organization qualifies as an "insured" under the Who Is An Insured provision contained in Paragraph A.1. of Section II — Covered Autos Liability Coverage in the Business Auto and Motor Carrier Coverage Forms and Paragraph D.2. of Section I — Covered Autos Coverages of the Auto Dealers Coverage Form. CA 20 48 10 13 © Insurance Services Office, Inc., 2011 Page 1 of 1 POLICY NUMBER: ESAL2210000563-03 COMMERCIAL AUTO CA 01 05 0821 00 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. WAIVER OF TRANSFER OF RIGHTS OF RECOVERY (WAIVER OF SUBROGATION - SCHEDULED) This endorsement modifies insurance provided under the following: BUSINESS AUTO COVERAGE FORM BUSINESS AUTO PHYSICAL DAMAGE COVERAGE FORM GARAGE COVERAGE FORM MOTOR CARRIER COVERAGE FORM TRUCKERS COVERAGE FORM With respect to coverage provided by this endorsement, the provisions of the Coverage Form apply unless modi- fied by the endorsement. This endorsement changes the policy effective on the inception date of the policy unless another date is indicated below. Named Insured: Combined Cutting Contractors Inc Endorsement Effective Date: 11/09/2023 SCHEDULE Name(s) Of Person(s) Or Organization(s): Any person(s) or organization(s) for whom you are required to waive subrogation with respect to the coverage provided under this Coverage Form Information required to complete this Schedule, if not shown above, will be shown in the Declarations. The Transfer Of Rights Of Recovery Against Oth- ers To Us Condition does not apply to the person(s) or organization(s) shown in the Schedule above, but only to the extent that subrogation is waived prior to the "accident" or the "loss" under a contract with that person or organization. CA 01 05 0821 00 Includes copyrighted material of Insurance Services Office, Inc. with Page 1 of 1 ❑ its permission.