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HomeMy WebLinkAboutMackay Sposito - PSA for COP Landscape StandardsANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? INSR ADDL SUBR LTR INSD WVD PRODUCER CONTACT NAME: FAXPHONE (A/C, No):(A/C, No, Ext): E-MAIL ADDRESS: INSURER A : INSURED INSURER B : INSURER C : INSURER D : INSURER E : INSURER F : POLICY NUMBER POLICY EFF POLICY EXPTYPE OF INSURANCE LIMITS(MM/DD/YYYY)(MM/DD/YYYY) AUTOMOBILE LIABILITY UMBRELLA LIAB EXCESS LIAB WORKERS COMPENSATION AND EMPLOYERS' LIABILITY DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) AUTHORIZED REPRESENTATIVE EACH OCCURRENCE $ DAMAGE TO RENTEDCLAIMS-MADE OCCUR $PREMISES (Ea occurrence) MED EXP (Any one person)$ PERSONAL & ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER:GENERAL AGGREGATE $ PRO-POLICY LOC PRODUCTS - COMP/OP AGGJECT OTHER:$ COMBINED SINGLE LIMIT $(Ea accident) ANY AUTO BODILY INJURY (Per person)$ OWNED SCHEDULED BODILY INJURY (Per accident)$AUTOS ONLY AUTOS HIRED NON-OWNED PROPERTY DAMAGE $AUTOS ONLY AUTOS ONLY (Per accident) $ OCCUR EACH OCCURRENCE CLAIMS-MADE AGGREGATE $ DED RETENTION $ PER OTH- STATUTE ER E.L. EACH ACCIDENT E.L. DISEASE - EA EMPLOYEE $ If yes, describe under E.L. DISEASE - POLICY LIMITDESCRIPTION OF OPERATIONS below INSURER(S) AFFORDING COVERAGE NAIC # COMMERCIAL GENERAL LIABILITY Y / N N / A (Mandatory in NH) SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. 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. 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). COVERAGES CERTIFICATE NUMBER:REVISION NUMBER: CERTIFICATE HOLDER CANCELLATION © 1988-2015 ACORD CORPORATION. All rights reserved.ACORD 25 (2016/03) CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DD/YYYY) $ $ $ $ $ The ACORD name and logo are registered marks of ACORD 2/18/2021 25658 MacKay & Sposito Inc DBA MacKay Sposito 1325 SE Tech Center Dr Ste 140 Vancouver, WA 98683 25623 A 1,000,000 X 6801J317949 12/31/2020 12/31/2021 1,000,000 Business Owners 5,000 Employers Liability 1,000,000 2,000,000 2,000,000 1,000,000B BA1R998391 12/31/2020 12/31/2021 10,000,000C CUP0G804100 12/31/2020 12/31/2021 10,000,000 10,000 C 6JUB5N298903 12/31/2020 12/31/2021 1,000,000 Y 1,000,000 1,000,000 D Professional Liab 107023673 12/31/2020 Per Claim 5,000,000 D Professional Liab 107023673 12/31/2020 12/31/2021 Aggregate 5,000,000 City of Pasco is named as additional insured with respect to work performed by the insured under written contract. City of Pasco 525 North 3rd P.O. Box 293 Pasco, WA 99301 MACKSPO-01 JHAYES Davidson & Associates Insurance Inc 11112 NE 51st Circle Vancouver, WA 98682 Margaret Rogers margaret@davidsoninsurance.com Travelers Indemnity Company Phoenix Insurance Company Travelers Prop & Cas of Americ Travelers Cas Ins Co of Americ X 12/31/2021 X X X X X X X X X Do not add this form to a policy. It is for informational purposes only.COMMERCIAL GENERAL LIABILITY THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. BLANKET ADDITIONAL INSURED (ARCHITECTS, ENGINEERS AND SURVEYORS) This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART 1.The following is added to SECTION II – WHO IS h.This insurance does not apply to "bodily AN INSURED:injury" or "property damage" caused by "your work" and included in the "products-Any person or organization that you agree in a completed operations hazard" unless the"written contract requiring insurance" to include as "written contract requiring insurance"an additional insured on this Coverage Part, but:specifically requires you to provide such a.Only with respect to liability for "bodily injury",coverage for that additional insured, and then "property damage" or "personal injury"; and the insurance provided to the additional insured applies only to such "bodily injury" orb.If, and only to the extent that, the injury or "property damage" that occurs before the enddamage is caused by acts or omissions of of the period of time for which the "writtenyou or your subcontractor in the performance contract requiring insurance" requires you toof "your work" to which the "written contract provide such coverage or the end of therequiring insurance" applies, or in connection policy period, whichever is earlier.with premises owned by or rented to you. 2.The following is added to Paragraph 4.a.ofThe person or organization does not qualify as an SECTION IV – COMMERCIAL GENERALadditional insured: LIABILITY CONDITIONS:c.With respect to the independent acts or The insurance provided to the additional insuredomissions of such person or organization; or is excess over any valid and collectible otherd.For "bodily injury", "property damage" or insurance, whether primary, excess, contingent or"personal injury" for which such person or on any other basis, that is available to theorganization has assumed liability in a additional insured for a loss we cover. However, ifcontract or agreement.you specifically agree in the "written contract requiring insurance" that this insurance providedThe insurance provided to such additional insured to the additional insured under this Coverage Partis limited as follows: must apply on a primary basis or a primary ande.This insurance does not apply on any basis to non-contributory basis, this insurance is primaryany person or organization for which to other insurance available to the additionalcoverage as an additional insured specifically insured which covers that person or organizationsis added by another endorsement to this as a named insured for such loss, and we will notCoverage Part.share with the other insurance, provided that: f.This insurance does not apply to the (1)The "bodily injury" or "property damage" forrendering of or failure to render any which coverage is sought occurs; and"professional services". (2)The "personal injury" for which coverage isg.In the event that the Limits of Insurance of the sought arises out of an offense committed;Coverage Part shown in the Declarations after you have signed that "written contractexceed the limits of liability required by the requiring insurance". But this insurance provided"written contract requiring insurance", the to the additional insured still is excess over validinsurance provided to the additional insured and collectible other insurance, whether primary,shall be limited to the limits of liability required excess, contingent or on any other basis, that isby that "written contract requiring insurance". available to the additional insured when thatThis endorsement does not increase the person or organization is an additional insuredlimits of insurance described in Section III – under any other insurance.Limits Of Insurance. CG D3 81 09 15 ú 2015 The Travelers Indemnity Company. All rights reserved.Page 1 of 2 Includes the copyrighted material of Insurance Services Office, Inc., with its permission MacKay & Sposito IncPolicy No. 6801J31794912/31/2020 - 12/31/2021 Do not add this form to a policy. It is for informational purposes only.COMMERCIAL GENERAL LIABILITY 3.The following is added to Paragraph 8., Transfer 4.The following definition is added to the Of Rights Of Recovery Against Others To Us,DEFINITIONS Section: of SECTION IV – COMMERCIAL GENERAL "Written contract requiring insurance" means thatLIABILITY CONDITIONS:part of any written contract under which you are We waive any right of recovery we may have required to include a person or organization as an against any person or organization because of additional insured on this Coverage Part, payments we make for "bodily injury", "property provided that the "bodily injury" and "property damage" or "personal injury" arising out of "your damage" occurs and the "personal injury" iswork" performed by you, or on your behalf, done caused by an offense committed:under a "written contract requiring insurance" with a.After you have signed that written contract;that person or organization. We waive this right only where you have agreed to do so as part of b.While that part of the written contract is in the "written contract requiring insurance" with effect; and such person or organization signed by you c.Before the end of the policy period.before, and in effect when, the "bodily injury" or "property damage" occurs, or the "personal injury" offense is committed. Page 2 of 2 ú 2015 The Travelers Indemnity Company. All rights reserved.CG D3 81 09 15 Includes the copyrighted material of Insurance Services Office, Inc., with its permission