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HomeMy WebLinkAbout131163 ADECCO INC & ITS SUBSIDIARIES - INSURANCE CERTIFICATE (4)a DATE(MM/DDIYYYY) k __ CERTIFICATE OF LIABILITY INSURANCE 03/1912015 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 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 Marsh USA, Inc. 1166 Avenue of the Americas New York, NY 10036 Attn: Adecco.certs@Marsh.com 370044-ALL-GAU WC-15-16 INSURED Adecco Inc. & its subsidiaries 10151 Deerwood Park Blvd. Building 200 Jacksonville, FL 32256 Fax:212-948-0018 NO AXA Insurance Company National Union Fire Insurance Co Of Pitt Insurance Company Of The State Of PA WA COVERAGES CERTIFICATE NUMBER: NYC-006685WO-06 REVISION NUMBER:1 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 IHE 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 LTR TYPE OF INSURANCE ADDL SUER POLICY NUMBER POLICY EFF MMM POLICY EXP MMIDD Y LIMITS A GENERAL LIABILITY X ' COMMERCIAL GENERAL LIABILITY CLAIMS -MADE a OCCUR PCS002071(15) 01/01/2015 01I0112016 EACH OCCURRENCE $ 2,000.000 DAMAGE T RENTED2000000 PREMISESEa occurrence $ MED EXP (Any one person) $ 5•000 PERSONAL & ADV INJURY $ 2,000,000 GENERAL AGGREGATE $ 4,000,000 GENT AGGREGATE LIMIT APPLIES PER: X POLICY X PRO- X LOC PRODUCTS-COMPIOP AGG $ 4,000,000 $ 8 B AUTOMOBILE LIABILITY X ANY AUTO ALL ONMED SCHEDULED AUTOS AUTOS HIRED AUTOS NON -OWNED AUTOS 5874044 (ADS) 5874046 (MA) 01/01/2015 01/01/2015 01/01/2016 01/01/2016 COMBINED SINGLE LIMIT Ea accident 2 DD0 000 BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ PROPERTY DAMAGE Per Ident $ $ A X UMBRELLA LM,B EXCESS LIAB X OCCUR CLAIMS -MADE XS002072(15) 01101/2015 01/01/2016 EACH OCCURRENCE $ 5,000,000 AGGREGATE $ 5,000,000 DELI I X I RETENTION $10,000 $ C C C WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANY PROPRIETORIPARTNER/EXECUTIVE YIN OFFICER/MEMBEREXCLUDED? (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below NIA 024508528 (ADS) 024508532 (CA) 024508533(FL) 01/0112015 01/01/2015 01/01/2015 01/01/2016 01/01/2016 01/01/2016 X I Imc STATU- I JOTH- E.L. EACH ACCIDENT S 2,000,000 E.L. DISEASE - EA EMPLOYE S 2.000,D00 I E L. DISEASE - POLICY LIMIT 2,000,000 I $ DESCRIPTION OF OPERATIONS I LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required) Branch Location. Adecco Engineenng & Technical, 4025 Automation Way F1, Fort Collins, CO 60525. CERTIFICATE HOLDER CANCELLATION City of Fort Collins SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Attn. Ed Bonnette THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 215 N. Mason St. ACCORDANCE WITH THE POLICY PROVISIONS. Fort Collins, CO 80522 AUTHORIZED REPRESENTATIVE of Marsh USA Inc. Jason Clarke_ ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25 (2010/05) The ACORD name and logo are registered marks of ACORD AGENCY CUSTOMER ID: 370044 LOC #: New York ARO® ADDITIONAL REMARKS SCHEDULE Page 2 of 2 AGENCY NAMED INSURED Marsh USA, Inc. Adecco Inc. 8 its subsidiaries 10151 Deerwood Park Blvd. Building 200 POLICY NUMBER Jacksonville, FL 32256 CARRIER NAIL CODE EFFECTIVE DATE: ADDITIONAL REMARKS THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, FORM NUMBER: 25 FORM TITLE: Certificate of Liability Insurance WORKERS COMP CONTINUED. POLICY NUMBER. 024508531 STATE: AK,AZ,VA EFFECTIVE: 1/112015- 11112016 PAPER: INSURANCE COMPANY OF THE STATE OF PA CARRIER: AIG POLICY NUMBER: 024508529 STATE: I L, KY, N C, N H, UT, V T EFFECTIVE: 11112015-111/2016 PAPER: INSURANCE COMPANY OF THE STATE OF PA CARRIER: AIG POLICY NUMBER: 024508534 STATE:ME EFFECTIVE: 1/l/2015- 1/l/2016 PAPER: INSURANCE COMPANY OF THE STATE OF PA CARRIER: AIG POLICY NUMBER, 0245GB536 STATE: MA, ND, WA, WI, WY EFFECTIVE: 1/112015- 1I1I2016 PAPER: INSURANCE COMPANY OF THE STATE OF PA CARRIER: AIG POLICY NUMBER. 024508530 STATE: NJ, PA EFFECTIVE: 1/1/2015- 1/l/2016 PAPER: INSURANCE COMPANY OF THE STATE OF PA CARRIER: AIG POLICY NUMBER: 024508535 STATE: MN EFFECTIVE: 1/l/2015- 1/l/2016 PAPER: THE INSURANCE COMPANY OF THE STATE OF PA CARRIER: AIG EXCESS WORKERS COMP-OHIO ONLY: INSURER: NATIONAL INSURANCE COMPANY OF THE STATE OF PA POLICY NUMBER: 9883942 EFFECTIVE: 1/112015- 111/2016 LIMITS: SIR.$3,000,000 EL EACH ACCIDENT I EL DISEASE I EL DISEASE - EACH EMPLOYEE: $1,000,0001$1,000,000 / $1,000,000 ACORD 101 (2008/01) © 2008 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD CERTIFICATE OF LIABILITY INSURANCE DAT03119015 IYVYY) 9I2015 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 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 Marsh USA, Inc. 1166 Avenue of the Americas New Yak, NY 10036 Attn: Adecco.certs@Marsh.com 370044-ALL-GAU WC-15-16 INSURED Adeao Inc. 8 its subsidiaries 10151 Deerwood Park Blvd. Building 200 Jacksonville, FL 32256 COVERAGES Fax. 212-948-0018 NO CERTIFICATE NUMBER: AXA Insurance WA WIRER C : Insurance Company Of The State Of PA iURER D : WA HIRER E : WRIER F : NYC-006685058-06 REVISION NUMBER:1 WA 19429 WA 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. IR TYPE OF INSURANCE ADOL VD POLICY NUMBER MWDDY E LTFF MM DDNYYY LIMITS LTR A GENERAL LIABILITY PCS002071(15) 01/0112015 01/01/2016 EACH OCCURRENCE $ 2,000,000 X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE I -XI OCCUR DAMAGE TO RENTED PREMISE E occurrence) $ 2,000,000 MED EXP (Any onePerson) $ 5,000 PERSONAL tt ADV INJURY It 2,000,000 GENERAL AGGREGATE S 4,000,000 AGGREGATE LIMIT APPLIES PER. PRODUCTS-COMP/OP AGG S 4,000,000 $ MGENL X POLICY X PRO- X LOC AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea accident BODILY INJURY (Per person) S ANY AUTO ALL OWNED SCHEDULED AUTOS AUTONON-S BODILY INJURY (Per accident) S PROPERTY DAMAGE Per accitlent $ OWNED HIRED AUTOS AUTOS UMBRELLA IJAB OCCUR EACH OCCURRENCE S AGGREGATE $ EXCESS LIAB CLAIMS -MADE DED I I RETENTION $ $ C WORKERS COMPENSATION 024508528 (ADS) 01/01/2015 0110112016 X I WC STATU- OTH- 1 TORY LIMITS ER C G AND EMPLOYERS' LIABILITY ANY PROPRIETOR/PARTNERIEXEW.NE YIN OFFICER/MEMBER EXCLUDED? a (Mandatory in NH) NIA 024508532(CA) 024508533 FL ( ) 01/01I2015 01101/2015 01/01/2016 01/0112016 E.L.EACHACCIDENT $ 2,000,000 E.L. DISEASE - EA EMPLOY $ 2,000,000 If yes describe under DESCRIPTION OF OPERATIONS beow E.L. DISEASE - POLICY LIMIT I S 2000000 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required) Branch Location. Adecco Staffing, 3711 JFK Parkway, Suite 305, Fort Collins, CO 80525. City of Fort Collins Attn. Ed Bonneme 215 N, Mason St. Fort Collins, CO 80524 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE of Marsh USA Inc. Jason Clarke ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25 (2010/05) The ACORD name and logo are registered marks of ACORD AGENCY CUSTOMER ID: 370044 LOC #: New York 4COR0® AnnITIONAI RFMARKR SCHFnill F AGENCY NAMED INSURED Marsh USA. Inc. Adecco Inc. 8 its subsidiaries 10151 Deerwood Park Blvd. POLICY NUMBER Building 200 Jacksonville, FL 32256 CARRIER NAIC CODE EFFECTIVE DATE: THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, FORM NUMBER: 25 FORM TITLE: Certificate of Liability Insurance WORKERS COMP CONTINUED. POLICY NUMBER. 024508531 STATE: AK,AZ,VA EFFECTIVE, 1/1/2015- 1/112016 PAPER: INSURANCE COMPANY OF THE STATE OF PA CARRIER. AIG POLICY NUMBER: 024508529 STATE: I L, KY, N C, N H, U T, VT EFFECTIVE: 1/112015- 1/1/2016 PAPER: INSURANCE COMPANY OF THE STATE OF PA CARRIER: AIG POLICY NUMBER: 024508534 STATE ME EFFECTIVE: 11112015-11112016 PAPER: INSURANCE COMPANY OF THE STATE OF PA CARRIER: AIG POLICY NUMBER: 024508536 STATE: MA, ND, WA, WI, WY EFFECTIVE: 1/112015-11112016 PAPER: INSURANCE COMPANY OF THE STATE OF PA CARRIER: AIG POLICY NUMBER: 024508530 STATE: NJ, PA EFFECTIVE: VV2015- 111/2016 PAPER: INSURANCE COMPANY OF THE STATE OF PA CARRIER: AIG POLICY NUMBER. 024508535 STATE: MN EFFECTIVE: 11112015- 11112016 PAPER: THE INSURANCE COMPANY OF THE STATE OF PA CARRIER: AIG EXCESS WORKERS COMP-OHIO ONLY: INSURER: NATIONAL INSURANCE COMPANY OF THE STATE OF PA POLICY NUMBER. 9883942 EFFECTIVE: 11112015-1/l/2016 LIMITS: SIR:$3,000,000 EL EACH ACCIDENT / EL DISEASE I EL DISEASE - EACH EMPLOYEE. $1,000,0001$1,000,000 / $1,000,000 Paqe 2 of 2 ACORD 101 (2008/01) © 2008 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD o ,acoR® CERTIFICATE OF LIABILITY INSURANCE DATE (YYYY) 0311912015 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 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 Marsh USA, Inc. 1166 Avenue of the Americas CONTACT NAME: PHONE -- FAX WNo: — E-MAIL ADDRESS: New York, NY 10036 Ann: Adecco.certs@Marsh.com Fax: 212-948-0018 INSURE S AFFORDING COVERAGE NAIC # INSURER A : AXA Insurance Company 33022 370044-ALL-GAUWC-15-16 NO INSURED AdeccINSURER 10151 Inc. 8 subsidiaries 0151 Deerwood Park Blvd. B : NIA NIA INsuRER c :Insurance Company Of The Stale Of PA 19429 INSURER D : N/A WA Building 200 Jacksonville, FL 32256 INSURER E : INSURER F : COVFRAr:FS CFRTIFICATF NUMBER- NYC-006685059-06 REVISION NUMBER:1 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 LTR TYPE OF INSURANCE ADDL SUER POLICY NUMBER POLICY EFF IM/DDMf POLICY EXP MM/DD/YYYY LIMITS A GENERAL LIABILITY X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE M OCCUR PCS002071(15) 01/01/2015 01/01/2016 EACH OCCURRENCE $ 2d00.000 DAMAGE TO RENTEU-- PREMISES Ea occurrence $ 2,000,000 MED EXP (Any one person) $ 5'000 PERSONAL &ADV INJURY $ 2,000,000 GENERAL AGGREGATE $ 4,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: X I POLICY X PRO- X LOC PRODUCTS - COMP/OP AGG $ 4,000,000 $ AUTOMOBILE LIABILITY ANY AUTO ALL OWNED SCHEDAUTOSULED AUTOS NON -OWNED HIRED AUTOS AUTOS COMBINED SINGLE LIMIT Ea accident BODILY INJURY (Par person) $ BODILY INJURY (Per accident) $ PROPERTYDAMAGE Per accident $ S UMBRELLA LIAR EXCESS LIAB OCCUR CLAIMS -MADE EACH OCCURRENCE $ AGGREGATE $ DED I I RETENTION $ $ C C C WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE YIN � OFFICER/MEMBER EXCLUDED? (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below A NIA 024508528 (AOS) 024508532 (CA) FL 024508533 ( ) 01101/2015 01101/2015 0110112015 01/01/2016 01/01/2016 01/0112016 cvC STATu- OTH- E.L. EACH ACCIDENT $ ZODOA00 E.L. DISEASE -EA EMPLOYE $ 2,000,000 E.L. DISEASE -POLICY LIMIT 1 $ y OQ0 (N10 DESCRIPTION OF OPERATIONS I LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, If more space Is required) Branch Location: Adecco Engineedng & Technical, 300 E. Boardwalk, Fort Collins, CO 80525, CFRTIFICATF FIOI nFR CANCFI I ATION City of Fort Collins SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Attn: Ed Bonnefte THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 215 N. Mason St. ACCORDANCE WITH THE POLICY PROVISIONS. Fort Collins, CO 80524 AUTHORIZED REPRESENTATIVE of Marsh USA Inc. Jason Clarke [A— ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25 (2010/05) The ACORD name and logo are registered marks of ACORD AGENCY CUSTOMER ID: 370044 LOC #: New York Ao ADDITIONAL REMARKS SCHEDULE Page _2 of 2 AGENCY NAMED INSURED Marsh USA, Inc. Adecco Inc. & its 1015i1 Deernood Park Blvd.s Building 200 POLICY NUMBER Jacksonville, FL 32256 CARRIER NAIC CODE EFFECTIVE DATE: THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, FORM NUMBER: 25 FORM TITLE: Certificate of Liability Insurance WORKERS COMP CONTINUED. POLICY NUMBER: 024508531 STATE: AK,AZ,VA EFFECTIVE: 1/l/2015- 111/2016 PAPER: INSURANCE COMPANY OF THE STATE OF PA CARRIER: AIG POLICY NUMBER: 024508529 STATE: IL,KY,NC, NH, UT,VT EFFECTIVE. 1/1/2015- 111/2016 PAPER: INSURANCE COMPANY OF THE STATE OF PA CARRIER: AIG POLICY NUMBER: 024508534 STATE:ME EFFECTIVE: 1/1/2015- 111I2016 PAPER: INSURANCE COMPANY OF THE STATE OF PA CARRIER: AIG POLICY NUMBER. 024508536 STATE: MA, NO, WA, WI, WY EFFECTIVE: 11112015- 11112016 PAPER: INSURANCE COMPANY OF THE STATE OF PA CARRIER: AIG POLICY NUMBER: 024508530 STATE:NJ,PA EFFECTIVE: 1/1/2015- IJ112016 PAPER: INSURANCE COMPANY OF THE STATE OF PA CARRIER: AIG POLICY NUMBER: 02450a535 STATE: MN EFFECTIVE: 11112015- 1I112016 PAPER: THE INSURANCE COMPANY OF THE STATE OF PA CARRIER: AIG EXCESS WORKERS COMP-OHIO ONLY: INSURER: NATIONAL INSURANCE COMPANY OF THE STATE OF PA POLICY NUMBER: 9883942 EFFECTIVE: 111/2015-111/2016 LIMITS: SIR:$3,000,000 EL EACH ACCIDENT I EL DISEASE I EL DISEASE - EACH EMPLOYEE. $1.000,0001$1,000,000 / $1,000.000 ACORD 101 (2008/01) © 2008 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD