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HomeMy WebLinkAbout233_Arlington-COI-2024 71/5/2024 E(MM/DDYYY) A�" CERTIFICATE OF LIABILITY INSURANCE IY 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: Certificate Unit Edgewood Partners Ins Center PHONE FAX 5909 Peachtree Dunwoody Road A/C No Ext: 404-781-1700 A/c No), Suite 800 ADDRESS: certificate@epicbrokers.com Atlanta GA 30328 INSURER(S)AFFORDING COVERAGE NAIC# License#:OB29370 INSURERA: Liberty Mutual Fire Ins Co 23035 INSURED DYCOMIND INSURER B: LM Insurance Corporation 33600 CABLECOM, LLC 19910 North Creek Parkway North, Suite 100 INSURERC: Bothell, WA 98011 INSURER D INSURER E INSURER F COVERAGES CERTIFICATE NUMBER:1802133933 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/DDIYYYY MM/DD/YYYY A X COMMERCIAL GENERAL LIABILITY TB2-631-510825-234 1/31/2024 1/31/2025 EACH OCCURRENCE $5,000,000 Fv� DAMAGE CLAIMS-MADE OCCUR PREM SES�a o_cur RENTEence $1,000,000 MED EXP(Any one person) $ PERSONAL&ADV INJURY $5,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $10,000,000 POLICY PREl LOC PRODUCTS-COMP/OP AGG $10,000,000 OTHER: $ A AUTOMOBILE LIABILITY AS2-631-004260-024 1/31/2024 1/31/2025 COMBINED SINGLE LIMIT $5,000,000 Ea accident X ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS X HIRED X NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY AUTOS ONLY Per accident A X UMBRELLA LIAB X OCCUR TL2-631-510856-294 1/31/2024 1/31/2025 EACH OCCURRENCE $5,000,000 EXCESS LIAB CLAIMS-MADE AGGREGATE $5,000,000 DED RETENTION$ $ B WORKERS COMPENSATION WA5-63D-004260-034(AOS) 1/31/2024 1/31/2025 X STATUTE PER OERH B AND EMPLOYERS'LIABILITY Y/N WC5-631-004260-044(WI) 1/31/2024 1/31/2025 ANYPROPRIETOR/PARTNER/EXECUTIVE ❑ E.L.EACH ACCIDENT $1,000,000 OFFICER/MEMBER EXCLUDED? NIA (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 I LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) Certificate applies to work performed by CableCom @ within the City of Arlington,WA.The City of Arlington,WA.it's Directors,Officers,Agents, Employees and Volunteers are included as Additional Insureds as respects to General Liability as required by written contract..30-day notice of cancellation,except 10 days for non-payment of premium,applies to the extent required by written contract. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN City of Arlington Attn: Community and Economic ACCORDANCE WITH THE POLICY PROVISIONS. Development Department 18204 59th Avenue NE AUTHORIZED REPRESENTATIVE Arlington WA 98223 @ 1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD POLICY NUMBER: AS2-631-004260-024 COMMERCIAL AUTO CA20481013 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. SCHEDULE Name Of Person(s) Or Organization(s): Any Person(s)or Organization(s) as required by written contract prior to loss on file with broker. 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 AS2-631-004260-024 Issued by Liberty Mutual Fire Insurance Co. THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. NOTICE OF CANCELLATION TO THIRD PARTIES This endorsement modifies insurance provided under the following: BUSINESS AUTO COVERAGE PART MOTOR CARRIER COVERAGE PART GARAGE COVERAGE PART TRUCKERS COVERAGE PART EXCESS AUTOMOBILE LIABILITY INDEMNITY COVERAGE PART SELF-INSURED TRUCKER EXCESS LIABILITY COVERAGE PART COMMERCIAL GENERAL LIABILITY COVERAGE PART EXCESS COMMERCIAL GENERAL LIABILITY COVERAGE PART PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE PART LIQUOR LIABILITY COVERAGE PART COMMERCIAL LIABILITY— UMBRELLA COVERAGE FORM Schedule Name of Other Person(s) / Email Address or mailing address: Number Days Notice: Organ ization s : Per schedule on file with the Per schedule on file with the company 75 or as required by written company contract, whichever is less, per the schedule on file with the company A. If we cancel this policy for any reason other than nonpayment of premium, we will notify the persons or organizations shown in the Schedule above. We will send notice to the email or mailing address listed above at least 10 days, or the number of days listed above, if any, before the cancellation becomes effective. In no event does the notice to the third party exceed the notice to the first named insured. B. This advance notification of a pending cancellation of coverage is intended as a courtesy only. Our failure to provide such advance notification will not extend the policy cancellation date nor negate cancellation of the policy. All other terms and conditions of this policy remain unchanged. LIM 99 01 05 11 ©2011 Liberty Mutual Group of Companies. All rights reserved. Page 1 of 1 Includes copyrighted material of Insurance Services Office, Inc., with its permission. POLICY NUMBER: AS2-631-004260-024 COMMERCIAL AUTO CA04441013 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. WAIVER OF TRANSFER OF RIGHTS OF RECOVERY AGAINST OTHERS TO US (WAIVER OF SUBROGATION) 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. SCHEDULE Name(s) Of Person(s) Or Organization(s): Any person or organization from whom you perform work under a written contract if the contract requires you to obtain this agreement from us, but only if the contract is executed prior to the injury or damage occurring. Information required to complete this Schedule, if not shown above, will be shown in the Declarations. The Transfer Of Rights Of Recovery Against Others To Us condition does not apply to the person(s) or organization(s) shown in the Schedule, 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 04 44 10 13 © Insurance Services Office, Inc., 2011 Page 1 of 1 POLICY NUMBER: TB2-631-510825-234 COMMERCIAL GENERAL LIABILITY CG 20 37 04 13 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) Or Organization(s) Location And Description Of Completed Operations All persons or organizations for whom you have agreed All locations as required by a written contract or in a written contract or agreement, prior to an agreement entered into prior to an "occurrence" or "occurrence" or offense, to provide additional insured offense. status. 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 B. With respect to the insurance afforded to these include as an additional insured the person(s) or additional insureds,the following is added to Section organization(s) shown in the Schedule, but only III— Limits Of Insurance: with respect to liability for "bodily injury" or If coverage provided to the additional insured is "property damage" caused, in whole or in part, by required by a contract or agreement,the most we will "your work" at the location designated and pay on behalf of the additional insured is the amount described in the Schedule of this endorsement of insurance: performed for that additional insured and included in the "products-completed operations hazard". 1. Required by the contract or agreement; or However: 2. Available under the applicable Limits of Insurance 1. The insurance afforded to such additional shown in the Declarations; insured only applies to the extent permitted by whichever is less. law; and This endorsement shall not increase the applicable 2. If coverage provided to the additional insured Limits of Insurance shown in the Declarations. 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. CG 20 37 04 13 © Insurance Services Office, Inc., 2012 Page 1 of 1 POLICY NUMBER: TB2-631-510825-234 COMMERCIAL GENERAL LIABILITY CG 20 10 04 13 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 A. Section II — Who Is An Insured is amended to 1. All work, including materials, parts or equipment include as an additional insured the person(s) or furnished in connection with such work, on the organization(s) shown in the Schedule, but only project (other than service, maintenance or with respect to liability for "bodily injury", "property repairs) to be performed by or on behalf of the damage" or "personal and advertising injury" additional insured(s) at the location of the caused, in whole or in part, by: covered operations has been completed; or 1. Your acts or omissions; or 2. That portion of "your work" out of which the 2. The acts or omissions of those acting on your injury or damage arises has been put to its behalf; intended use by any person or organization other than another contractor or subcontractor in the performance of your ongoing operations for engaged in performing operations for a principal the additional insured(s) at the location(s) as a part of the same project. designated above. C. With respect to the insurance afforded to these However: additional insureds, the following is added to 1. The insurance afforded to such additional Section III— Limits Of Insurance: insured only applies to the extent permitted by If coverage provided to the additional insured is law; and required by a contract or agreement, the most we 2. If coverage provided to the additional insured is will pay on behalf of the additional insured is the required by a contract or agreement, the amount of insurance: insurance afforded to such additional insured 1. Required by the contract or agreement; or will not be broader than that which you are required by the contract or agreement to provide 2. Available under the applicable Limits of for such additional insured. Insurance shown in the Declarations; B. With respect to the insurance afforded to these whichever is less. additional insureds, the following additional This endorsement shall not increase the applicable exclusions apply: Limits of Insurance shown in the Declarations. This insurance does not apply to "bodily injury" or "property damage" occurring after: CG 20 10 04 13 © ISO Properties, Inc., 2012 Page 1 of 2 ❑ SCHEDULE Name Of Additional Insured Person(s) Or Organization(s) Locations Of Covered Operations All persons or organizations for whom you have agreed All locations as required by a written contract or in a written conract or agreement, prior to an agreement entered into prior to an `occurrence" or "occurrence" or offense, to provide additional insured offense. status. Information required to complete this Schedule, if not shown above, will be shown in the Declarations. CG 20 10 04 13 © Insurance Services Office, Inc., 2012 Page 2 of 2 Policy Number TB2-631-510825-234 Issued by Liberty Mutual Fire Insurance Co. THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. NOTICE OF CANCELLATION TO THIRD PARTIES This endorsement modifies insurance provided under the following: BUSINESS AUTO COVERAGE PART MOTOR CARRIER COVERAGE PART GARAGE COVERAGE PART TRUCKERS COVERAGE PART EXCESS AUTOMOBILE LIABILITY INDEMNITY COVERAGE PART SELF-INSURED TRUCKER EXCESS LIABILITY COVERAGE PART COMMERCIAL GENERAL LIABILITY COVERAGE PART EXCESS COMMERCIAL GENERAL LIABILITY COVERAGE PART PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE PART LIQUOR LIABILITY COVERAGE PART COMMERCIAL LIABILITY— UMBRELLA COVERAGE FORM Schedule Name of Other Person(s) / Email Address or mailing address: Number Days Notice: Organ ization s : Per schedule on file with the Per schedule on file with the company 75 or as required by written company contract, whichever is less, per the schedule on file with the company A. If we cancel this policy for any reason other than nonpayment of premium, we will notify the persons or organizations shown in the Schedule above. We will send notice to the email or mailing address listed above at least 10 days, or the number of days listed above, if any, before the cancellation becomes effective. In no event does the notice to the third party exceed the notice to the first named insured. B. This advance notification of a pending cancellation of coverage is intended as a courtesy only. Our failure to provide such advance notification will not extend the policy cancellation date nor negate cancellation of the policy. All other terms and conditions of this policy remain unchanged. LIM 99 01 05 11 ©2011 Liberty Mutual Group of Companies. All rights reserved. Page 1 of 1 Includes copyrighted material of Insurance Services Office, Inc., with its permission. Policy Number TB2-631-510825-234 Issued by LIBERTY MUTUAL FIRE INSURANCE COMPANY THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. PRIMARY AND NONCONTRIBUTORY— OTHER INSURANCE CONDITION This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE PART The following is added to Section IV — Conditions 4. Other Insurance 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 prior to a loss, that this insurance would be primary and would not seek contribution from any other insurance available to the additional insured. (3) This insurance is excess over any other insurance available to the additional insured for which it is also covered as an additional insured by attachment of an endorsement to another policy providing coverage for the same 'occurrence", claim or"suit'. LID 24 153 08 16 ©2016 Liberty Mutual Insurance Page 1 of 1 Includes copyrighted material of Insurance Services Office, Inc.,with its permission. POLICY NUMBER: T132-631-510825-234 COMMERCIAL GENERAL LIABILITY CG24041219 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. WAIVER OF TRANSFER OF RIGHTS OF RECOVERY AGAINST OTHERS TO US (WAIVER OF SUBROGATION) This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART ELECTRONIC DATA LIABILITY COVERAGE PART LIQUOR LIABILITY COVERAGE PART POLLUTION LIABILITY COVERAGE PART DESIGNATED SITES POLLUTION LIABILITY LIMITED COVERAGE PART DESIGNATED SITES PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE PART RAILROAD PROTECTIVE LIABILITY COVERAGE PART UNDERGROUND STORAGE TANK POLICY DESIGNATED TANKS SCHEDULE Name Of Person(s) Or Organization(s): As required by agreement entered into prior to loss. 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—Conditions: We waive any right of recovery against the person(s) or organization(s) shown in the Schedule above because of payments we make under this Coverage Part. Such waiver by us applies only to the extent that the insured has waived its right of recovery against such person(s) or organization(s) prior to loss. This endorsement applies only to the person(s) or organization(s) shown in the Schedule above. CG 24 04 12 19 © Insurance Services Office, Inc., 2018 Page 1 of 1 NOTICE OF CANCELLATION TO THIRD PARTIES A. If we cancel this policy for any reason other than nonpayment of premium, we will notify the persons or organizations shown in the Schedule below. We will send notice to the email or mailing address listed below at least 10 days, or the number of days listed below, if any, before cancellation becomes effective. In no event does the notice to the third party exceed the notice to the first named insured. B. This advance notification of a pending cancellation of coverage is intended as a courtesy only. Our failure to provide such advance notification will not extend the policy cancellation date nor negate cancellation of the policy. SCHEDULE Name of Other Person(s)/ Email Address or mailing address: Number Days Notice: Organization(s): List on file with the broker 30 All other terms and conditions of this policy remain unchanged. Issued by LM Insurance Corporation For attachment to Policy No. WA5-63D-004260-034 Effective Date 1/31/2024 Premium$ Issued to WC 99 20 75 ©2016 Liberty Mutual Insurance Page 1 of 1 Ed. 12/01/2016 NOTICE OF CANCELLATION TO THIRD PARTIES A. If we cancel this policy for any reason other than nonpayment of premium, we will notify the persons or organizations shown in the Schedule below. We will send notice to the email or mailing address listed below at least 10 days, or the number of days listed below, if any, before cancellation becomes effective. In no event does the notice to the third party exceed the notice to the first named insured. B. This advance notification of a pending cancellation of coverage is intended as a courtesy only. Our failure to provide such advance notification will not extend the policy cancellation date nor negate cancellation of the policy. SCHEDULE Name of Other Person(s)/ Email Address or mailing address: Number Days Notice: Organization(s): List on file with the broker 30 All other terms and conditions of this policy remain unchanged. Issued by LM Insurance Corporation For attachment to Policy No. WC5-631-004260-044 Effective Date 1/31/2024 Premium$ Issued to WC 99 20 75 ©2016 Liberty Mutual Insurance Page 1 of 1 Ed. 12/01/2016 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 Where Required By Contract Or Written Agreement Prior To Loss And Allowed By Law. Issued by: LM Insurance Corporation For attachment to Policy No WA5-63D-004260-034 Effective Date 1/31/2024 Premium$ Issued to: WC 00 03 13 © 1983 National Council on Compensation Insurance, Inc. Page 1 of 1 Ed. 4/1/1984 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 Where Required By Contract Or Written Agreement Prior To Loss And Allowed By Law. Issued by: LM Insurance Corporation For attachment to Policy No WC5-631-004260-044 Effective Date 1/31/2024 Premium$ Issued to: WC 00 03 13 © 1983 National Council on Compensation Insurance, Inc. Page 1 of 1 Ed. 4/1/1984