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HomeMy WebLinkAboutLumen Technologies, Inc. - INSURANCE CERTIFICATE AC40RD® CERTIFICATE OF LIABILITY INSURANCE 7DATE(MM/DD/YYYY) 4I2023 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 MARSH USA LLC. NAME: CA License#0437153 PHIC ON14o,EExtla (FAA/C.No): 1301 5th Avenue,Suite 1900 ADDRESS: Seattle,WA 98101-2682 Attn:Seattle.certrequest@marsh.com/Fax:212-9484326 INSURERS AFFORDING COVERAGE NAIC# CN102197661-STND-ALL-23-24 INSURER A:Greenwich Insurance Company 22322 INSURED Lumen Technologies,Inc. INSURER B:XL Specialty Insurance Co. 37885 and all subsidiaries,including but not limited to: INSURER C:Allianz Underwriters Ins Co 36420 Qwest Corpora8on;Embarq Corporation;Level 3 Communications,LLC and INSURER D: CenturyLink Communications,LLC 100 CenturyLink Dr. INSURER E: Monroe,LA 71203 INSURER F: COVERAGES CERTIFICATE NUMBER: SEA-003814545-11 REVISION NUMBER: 9 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 I TYPE OF INSURANCE ADDL SUER POLICY EFF POLICY EXP LTR POLICYNUMBER MM/DD/YYYY MMIDD/YYYY LIMITS A X COMMERCIAL GENERAL LIABILITY X X RGD500033311 09/01/2023 09/01/2024 EACH OCCURRENCE $ 3,000,000 CLAIMS-MADE X OCCUR DAMAGE TO RENTED SOO,000 PREMISES Ea occurrence $ X CONTRACTUAL LIABILITY MED EXP(Any one person) $ 10,000 PERSONAL&ADV INJURY $ 3,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 15,000,000 1:1PRO ❑ LOC 15,000,000POLICY JECT - $ OTHER: $ A AUTOMOBILE LIABILITY X X RAD500033411 09/01/2023 09/01/2024 COMBINED SINGLE LIMIT $ 2,000,000 Ea accident X ANY AUTO Auto Physical Damage-Self Insured BODILY INJURY(Per person) $ X OWNED SCHEDULED BODILY INJURY AUTOS ONLY AUTOS (Per accident) $ X HIRED X NON-OWNED PROPERTY DAMAGE AUTOS ONLY AUTOS ONLY Per accident $ X UMBRELLALIAB X OCCUR X X U5Z000023220 09/01/2023 09/01/2024 EACH OCCURRENCE $ 10,000,000 EXCESS LIAR CLAIMS-MADE AGGREGATE $ 10,000,000 DED RETENTION$ $ B WORKERS COMPENSATION X RWD500032911(ADS) 799702T 9/01/2 224 X PER OTH- B AND EMPLOYERS'LIABILITY Y/N STATUTE ER ANYPROPRIETOR/PARTNER/EXECUTIVE RWR500033011(WI) 09101I2023 09/01/2024 1,000,000 B OF EXCLUDED? �N N/A $ (Mand E.L.EACH ACCIDENT atory in NH) RWE500033111(WA) 09/0112023 09/0112024 E.L.DISEASE-EA EMPLOYEE $ 1,000,000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ B yes,describe under RWE500033211(OH) 09/01/2023 09/01/2024 1,000,000 D C Technology E&O incl. U5Z000023220 09/01/2023 09/01/2024 Each Claim/Aggregate 10,000,000 Cyber/Privacy Liability Retention 5,000,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached If more space is required) City of Fort Collins is included as Additional Insured as respects their interest in the operations of the Named Insured as required by contract or agreement regarding General Liability. CERTIFICATE HOLDER CANCELLATION City of Fort Collins SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Engineering Dept. THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 281 N.College Avenue ACCORDANCE WITH THE POLICY PROVISIONS. PO Box 580 Fort Collins,CO 80522-0580 AUTHORIZED REPRESENTATIVE of Marsh USA LLC 01988-2016 ACORD CORPORATION. All rights reserved. ACORD 26(2016/03) The ACORD name and logo are registered marks of ACORD AGENCY CUSTOMER ID: CN102197661 _ LOC#: Seattle ACQ® ADDITIONAL REMARKS SCHEDULE Page 2 of 2 AGENCY NAMED INSURED MARSH USA LLC. Lumen Technologies,Inc. and all subsidiaries,including but not limited to: POLICY NUMBER Qwest Corporation,Embarq Corporation;Level 3 Communications,LLC and CenturyLink Communications,LLC 100 CenturyLink Dr. CARRIER NAIC CODE Monroe,LA 71203 EFFECTIVE DATE: ADDITIONAL REMARKS THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, FORM NUMBER: 25 FORM TITLE: Certificate of Liability Insurance -------------------GENERAL LIABILITY------------------- Automatic Additional Insured's Primary Coverage Additional Insured as respects your interest in the operations of the Named Insured as required by contract or agreement. Coverage provided by the above General Liability policy shall be primary and is limited to liability arising out of Named Insured's ownership and/or operations. Any insurance carried by the additional insured shall not be contributory insurance. Waiver of Transfer of Rights of Recovery Against Others to Us(Waiver of Subrogation)—any person or organization with wham you have entered into a contract or agreement,or by statute,law or code of ordinance. Separation of Insureds Applies. Insurance covers incidents that occur within 50'of railroad property,any railroad exclusions have been deleted per endorsement CG2417. -----------------AUTOMOBILE LIABILITY------------------- Any person or organization you are required in a written contract,agreement,statute,law or code of ordinances provided the"bodily injury"or"property damage"occurs subsequent to the executive of the contract,agreement,statute,law or code of ordinances. Lessor-Additional Insured and Loss Payee-All Lessors Waiver of Transfer of Rights of Recovery Against Others to Us(Waiver of Subrogation)—Any person or organization with whom you have waived prior to the"accident"or the"loss" under a contract with that person or organization,or under statute,law or code of ordinances. --------WORKERS'COMPENSATION AND EMPLOYER'S LIABILITY AND EXCESS WORKERS'COMPENSATION AND EMPLOYER'S LIABILITY(OH&WA-SELF-INSURED- $1,000,000 RETENTION) -------- Waiver of Our Right to Recover from others Endorsement—Where required by written agreement signed prior to loss,or required by statute,law or code of ordinances executed prior to loss. -----------------EXCESSIUMBRELLA---------------- Coverage applies per occurrence.Additional Insured as respects your interest in the operations of the Named Insured as required by contract or agreement.Waiver of Transfer of Rights of Recovery Against Others to Us(Waiver of Subrogation)-Any person or organization with whom you have entered into a contract or agreement,but only to the extent required by such contract or agreement.Separation of Insureds Applies. ------------------COMMERCIAL CRIME-FIDELITY BOND------------- Carrier:XL Specialty Insurance Company Policy Number:ELU19204423 Effective Dates:09/01/2023-09/01/2024 Deductible:$2,500,000 Each Occurrence:$15,000,000 ------------------U.S.PROPERTY ---—-- Carrier:Allianz Underwriters Insurance Company Policy Number:U5Z000023220 Effective Dates:09/01/2023-09/01/2024 Limit:$25,000,000 Deductible:$25,000,000 Property Coverage:"All Risk"of Direct Physical Loss or Damage to All Real and Personal Property,including Boiler&Machinery,Earthquake,Flood and Wind-Replacement Cost Basis,and Business Interruption-Actual Loss Sustained. Loss Payee or mortgagee as required by written contract/loan agreement to the the extent of your insurable interest.Waiver of Subrogation-Any person or organization whom you have entered into a contract or agreement,but only to the extent required by such contract or agreement.Other deductibles may apply as per policy terms and conditions. ACORD 101 (2008/01) ©2008 ACORD CORPORATION. All rights I The ACORD name and logo are registered marks of ACORD 0334-01-00-0001361-0002-0003110