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HomeMy WebLinkAboutCERTIFICATE OF LIABILITY INSURANCE - 23-00973 - Phoenix Fire - Fire Safety CertificationSHOULD 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-MAILADDRESS: 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 EROTH-STATUTEPER LIMITS(MM/DD/YYYY)POLICY EXP(MM/DD/YYYY)POLICY EFFPOLICY NUMBERTYPE OF INSURANCELTRINSR 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 12/19/2023 The Millward Agency,Inc. 11142 Highland Blvd Highland UT 84003 Customer Service 801-216-4545 801-216-4275 certs@millwardagency.com License#:334384 Lloyd's 15642 BICT686000 Service American Indemnity Company 39152PhoenixFireProtection,LLC 4130 Airport Rd Nampa ID 83687 Progressive Casualty Ins Co 24260 1963682557 A X 1,000,000 X 100,000 10,000 1,000,000 2,000,000 X Y Y SP2230285 8/6/2023 8/6/2024 2,000,000 C 1,000,000 X X X Y Y 960406424 8/6/2023 8/6/2024 A X X 1,000,000YSP2X2302858/6/2023Y 8/6/2024 1,000,000 X 0 B X Y Y SAMTWC10009101 7/1/2023 7/1/2024 1,000,000 1,000,000 1,000,000 A Professional Liability Pollition Liability Y Y SP2230285 8/6/2023 8/6/2024 Limit Aggregate Pollution Limit 1,000,000 2,000,000 1,000,000 General Liability Blanket Additional Insured status for ongoing/completed operations per CG20100413 &CG20370413.General Liability Primary & Non-Contributory per CG20010413.General Liability Blanket Waiver of Subrogation per CG24040509.General Liability Per Project per GL00101115.Umbrella is form following.Pollution Liability is included under the umbrella.Blanket Waiver for Workers Comp per WC000313.Commercial Auto Blanket Additional Insured,Primary,and Waiver per forms,CA7211,CA0449F,CA7212,&CA7241. Inland Marine Coverage:Policy #BMO63448904 Leased/Rented Equipment Limit:$500,000;Deductible:$500 City of Rexburg 35 N 1st E Rexburg ID 83440 SP2230285 SP2230285 POLICY NUMBER:SP2230285 SP2230285 : SP2230285 CA-7211(10-98) Page 1 of 1 CA-7211(10-98)BLANKET ADDITIONAL INSURED This endorsement modifies insurance prov ided under the following: BUSINESS AUTO COVERAGE FORM GARAGE COVERAGE FORM MOTOR CARRIER COVERAGE FORM 1.W ho Is an Insured under Section II -Liability Cov erage is amended to include any person or or- ganization you are required to add as an additional insured on this policy under a written contract or agreement currently in effect or becoming effectiv e during the term of the policy,prov ided that a cer- tificate of insurance showing that person or organiza- tion as additional insured has been issued. 2.The insurance prov ided by this endorsement ap- plies only with respect to liability arising out of oper- ations performed for the additional insured by you. 3.The Limits of Insurance applicable to the addi- tional insured are those specified in the written con- tract or agreement or in the Declarations for this Cov erage Form,whichev er is less.These Limits of Insurance are inclusiv e and not in addition to the Limits of Insurance shown in the Declarations. Includes copyrighted material of Insurance Services Office, Inc., with its permission. CA-7212(10-98) Page 1 of 1 BLANKET ADDITIONAL INSURED -PRIMARY CA-7212(10-98) This endorsement modifies insurance prov ided under the following: BUSINESS AUTO COVERAGE FORM GARAGE COVERAGE FORM MOTOR CARRIER COVERAGE FORM 1.W ho Is an Insured under Section II -Liability Cov erage is amended to include any person or or- ganization you are required to add as an additional insured on this policy under a written contract or agreement currently in effect or becoming effectiv e during the term of the policy,prov ided that a cer- tificate of insurance showing that person or organiza- tion as additional insured has been issued. 2.The insurance prov ided by this endorsement ap- plies only with respect to liability arising out of oper- ations performed for the additional insured by you. 3.The cov erage prov ided by this endorsement will be primary and noncontributory with respect to any other cov erage av ailable to the additional insured. 4.The Limits of Insurance applicable to the addi- tional insured are those specified in the written con- tract or agreement or in the Declarations for this Cov erage Form,whichev er is less.These Limits of Insurance are inclusiv e and not in addition to the Limits of Insurance shown in the Declarations. Includes copyrighted material of Insurance Services Office, Inc., with its permission. CA-0449F(11-16) Page 1 of 1 PRIMARY AND NONCONTRIBUTORY - OTHER INSURANCE CONDITION CA-0449F(11-16) Includes copyrighted material of Insurance Services Office, Inc., with its permission. This endorsement modifies insurance provided under the following: 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 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. CA-7241(3-03) Page 1 of 1 WAIVER OF TRANSFER OF RIGHTS OF RECOVERY AGAINST OTHERS TO US -AUTOMATIC STATUS CA-7241(3-03) This endorsement modifies insurance prov ided under the following: BUSINESS AUTO COVERAGE FORM GARAGE COVERAGE FORM MOTOR CARRIER COVERAGE FORM TRUCKERS COVERAGE FORM W ith respect to cov erage prov ided by this endorse- ment,the prov isions of the Cov erage Form apply unless modified by the endorsement. The following is added to the Transfer of Rights of Recov ery Against Others to Us Loss Condition: 1.W e waiv e any right of recov ery we may hav e against any person or organization described in paragraph 2 because of payments we make for bodily injury or property damage arising out of your use of a cov ered auto which occurs while under a contract with that person or organiza- tion. 2.The waiv er applies only to a person or or- ganization with whom you hav e a written con- tract or agreement requiring you to waiv e the rights of recov ery under this policy.This written contract or agreement must hav e been execut- ed prior to the occurrence causing bodily injury or property damage. Includes copyrighted material of Insurance Services Office, Inc., with its permission. WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 00 03 13 (Ed. 4-84) This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated. (The information below is required only when this endorsement is issued subsequent to preparation of the policy.) Insurance Company Countersigned by WC 00 03 13 (Ed. 4-84) © 1983 National Council on Compensation Insurance. Endorsement Effective Policy No.Endorsement No. Insured Phoenix Fire Protection, LLC Premium $ Service American Indemnity Company WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT We have the right to recover our payments from anyone liable for an injury covered by this policy. We will not enforce our right against the person or organization named in the Schedule. (This agreement applies only to the extent that you perform work under a written contract that requires you to obtain this agreement from us.) This agreement shall not operate directly or indirectly to benefit anyone not named in the Schedule. Schedule Blanket Waiver of Subrogation as required by written contract SAMTWC10009101 110,436 7/1/2023