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HomeMy WebLinkAboutCORRESPONDENCE - PURCHASE ORDER - 9185789 (2)ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? INSR ADDL SUBR LTR INSD WVD DATE (MM/DD/YYYY) PRODUCER CONTACT NAME: PHONE FAX (A/C, No, Ext): (A/C, No): E-MAIL ADDRESS: INSURER A : INSURED INSURER B : INSURER C : INSURER D : INSURER E : INSURER F : POLICY NUMBER POLICY EFF POLICY EXP TYPE OF INSURANCE (MM/DD/YYYY) (MM/DD/YYYY) LIMITS 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 RENTED CLAIMS-MADE OCCUR PREMISES (Ea occurrence) $ MED EXP (Any one person) $ PERSONAL & ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ PRO- POLICY JECT LOC PRODUCTS - COMP/OP AGG $ 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 DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT $ 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 POLICY NUMBER: 7110082470012 COMMERCIAL GENERAL LIABILITY CG 20 26 04 13 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - DESIGNATED PERSON OR ORGANIZATION This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Name of Additional Insured Person(s) or Organization(s): Blanket where required by written contract 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 include as an additional insured the person(s) or organization(s) shown in the Schedule, but only with respect to liability for "bodily injury", "property damage" or "personal and advertising injury" caused, in whole or in part, by your acts or omissions or the acts or omissions of those acting on your behalf: 1. In the performance of your ongoing operations; or 2. In connection with your premises owned by or rented to you. However: 1. The insurance afforded to such additional insured only applies to the extent permitted by law; and 2. If coverage provided to the additional insured 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. B. With respect to the insurance afforded to these additional insureds, the following is added to Section III - Limits Of Insurance: If coverage provided to the additional insured is required by a contract or agreement, the most we will pay on behalf of the additional insured is the amount of insurance: 1. Required by the contract or agreement; or 2. Available under the applicable Limits of Insurance shown in the Declarations; whichever is less. This endorsement shall not increase the applicable Limits of Insurance shown in the Declarations. CG 20 26 04 13 © Insurance Services Office, Inc., 2012 Page 1 of 1 Attachment Code: D550644 Certificate ID: 15775925 DocuSign Envelope ID: 6E13C9AE-FDA6-4FFC-9A43-9693F6FDE454 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. @VANTAGE FOR AUTOMOBILE This endorsement modifies insurance provided under the following: BUSINESS AUTO COVERAGE FORM The following schedule lists the coverage extensions provided by this endorsement. Refer to the individual provisions to determine the extent of your coverage. SCHEDULE OF COVERAGE EXTENSIONS 1. Additional Insured By Contract 12. Employee Hired Autos 2. Airbag Discharge 13. Fellow Employee Exclusion 3. Auto Theft Reward 14. Glass Repair — Waiver of Deductible 4. Blanket Waiver of Subrogation 15. Hired Auto Physical Damage Coverage 5. Bodily Injury Redefined — Mental Anguish 16. Lease Gap Coverage 6. Broad Form Named Insured 17. Liability Coverage — Supplementary Payments 7. Communications Equipment 18. Newly Formed or Acquired Organizations 8. Diminution in Value 19. Physical Damage — Transportation Expenses 9. Drive Other Car — Executive Officers 20. Rental Reimbursement Private Passenger 10. Duties In The Event of Accident, Claim, Suit or Loss Vehicles 11. Employees As Insureds 21. Towing — Any Covered Auto 1. ADDITIONAL INSURED BY CONTRACT The Who Is An Insured provision under SECTION II — LIABILITY COVERAGE is amended to include as an additional "insured" any person or organization with whom you agreed in a written contract, written agreement or permit, to provide insurance such as is afforded under this Coverage Form. Such person or organization is an "insured" only with respect to liability for "bodily injury" or "property damage" caused, in whole or in part by your maintenance, operation or use of your covered "autos". With respect to the insurance afforded to these additional "insureds", this insurance does not apply: a. Unless the written contract or agreement has been executed or the permit has been issued prior to the "bodily injury" or "property damage"; b. To any person or organization included as an "insured" by endorsement or in the Declarations; or c. To any lessor of "autos" when their contract or agreement with you for such leased "auto" ends. 2. AIRBAG DISCHARGE If you purchased physical damage coverage for a covered "auto" under this policy, we will pay to reset or replace an airbag that accidentally discharges without the vehicle being involved in an accident. No deductible applies to this additional coverage. However, this coverage only applies if the airbag is not covered under a manufacturer's warranty and you did not intentionally cause the airbag to discharge. 3. AUTO THEFT REWARD We will pay up to a $2,000 reward in the event of a covered loss, for information leading to the arrest and conviction of anyone stealing a covered "auto". A reward will not be paid to you, a family member, employee or any public official while performing their duty. 4. BLANKET WAIVER OF SUBROGATION The Transfer Of Rights of Recovery Against Others To Us condition under SECTION IV — BUSINESS AUTO CONDITIONS, paragraph A. LOSS CONDITIONS is replaced by the following: We will waive any right of recovery we may have against any person or organization because of payments we make for injury or damage arising out of the operation of a covered "auto" when you have assumed liability for such "bodily injury" or "property damage" under an "insured contract", provided the contract is in writing and executed prior to the "bodily injury" or "property damage". 5. BODILY INJURY REDEFINED — MENTAL ANGUISH The definition of "bodily injury" under SECTION V — DEFINITIONS is replaced by the following: "Bodily injury" means bodily injury, sickness, or disease sustained by a person, including mental anguish or death resulting from any of these at any time. Attachment Code: D548172 Certificate ID: 15775925 DocuSign Envelope ID: 6E13C9AE-FDA6-4FFC-9A43-9693F6FDE454 6. BROAD FORM NAMED INSURED a. The Who Is An Insured provision under SECTION II — LIABILITY COVERAGE is amended to include the following: Any organization which is a legally incorporated entity in which you own a financial interest of more than 50% of the voting stock on the effective date of this Coverage Form will be a Named Insured until the 1801h day or the end of the policy period whichever comes first, provided there is no other similar insurance available to that organization. b. Paragraph a. of this provision 6. does not apply to "bodily injury" or "property damage" for which an "insured" is also an "insured" under any other automobile policy or would be an "insured" under such a policy, but for its termination or the exhaustion of its Limit of Insurance. 7. COMMUNICATIONS EQUIPMENT a. The exclusion for electronic equipment under Exclusions of SECTION III — PHYSICAL DAMAGE COVERAGE does not apply to loss of any permanently installed, non-removable communications equipment designed for use as a: 1. Citizen's band radio; 2. Two-way mobile radio or telephone; 3. Scanning monitor receiver; or GPS Navigation System, including its antenna and other accessories. b. No Deductible applies to this additional coverage. c. The most we will pay for this coverage is $5,000 per occurrence. 8. DIMINUTION IN VALUE The "diminution in value" exclusion under SECTION III — PHYSICAL DAMAGE COVERAGE, B. Exclusions does not apply if the covered "auto" is a private passenger "auto" and is leased, rented, hired or borrowed without a driver for a period of 30 days or less and is used in the conduct of the insured's business. The most we will pay for "loss" arising out of an "accident" is the lesser of $7,500 or 20% of the actual cash value of the "auto" as determined by Kelley Blue Book or other independent valuation sources. 9. DRIVE OTHER CAR — EXECUTIVE OFFICERS a. The Who Is An Insured provision under SECTION II — LIABILITY COVERAGE is amended to include: If you are designated in the Declarations as: 1. An individual; you and your spouse. 2. A partnership; your partners and their spouses. 3. An organization other than an individual or a partnership; your "executive officers" and their spouses. b. SECTION II — LIABILITY COVERAGE and SECTION III — PHYSICAL DAMAGE COVERAGE are ex- tended to include "autos" you don't own, hire, lease or borrow while in the care, custody or control of an "insured" listed in 9.a. This does not include any "auto": 1. Owned by any "insured" listed in 9.a., or any member of their household, including any such "auto" that is owned but not insured; 2. Used by an "insured" listed in 9.a. while working in the business of selling, servicing, repairing or parking autos; or 3. Insured under another policy of insurance. If Medical Payments, Uninsured/Underinsured Motorist, Personal Injury Protection or other compulsory coverages required by the governing jurisdiction are covered on this policy, then insureds listed in 9.a. above and family members residing in the same households are "insureds" while: 1. Occupying as a passenger; or 2. A pedestrian when struck by, any "auto" you do not own, hire, lease or borrow, except any "auto" owned by that "insured" listed in 9.a, their family members or an "auto" insured under any other policy. c. The limits and deductibles applicable to this provision will be the largest applicable to any owned "auto" for the specific insurance. Attachment Code: D548172 Certificate ID: 15775925 DocuSign Envelope ID: 6E13C9AE-FDA6-4FFC-9A43-9693F6FDE454 d. The following definition is added to the DEFINITIONS section of the policy: "Executive officer" means a person holding any of the officer positions created by your charter, constitution, by-laws or any similar governing document. e. The Other Insurance Condition, under Section IV — BUSINESS AUTO CONDITIONS, does not apply to the provisions of this Drive Other Car endorsement. There is no "other insurance" applicable to this endorsement. 10. DUTIES IN THE EVENT OF ACCIDENT, CLAIM, SUIT OR LOSS Under SECTION IV - BUSINESS AUTO CONDITIONS - the Duties In The Event Of Accident, Claim, Suit Or Loss Condition is amended as follows: The requirements that you must: a. Notify us of an "accident", claim, "suit" or "loss"; and b. Send us documents concerning a claim or "suit", apply only when such "accident", claim, "suit" or "loss" is known to: a. You, if you are an individual; b. A partner, if you are a partnership; c. An executive officer of the corporation or insurance manager, if you are a corporation; or d. A manager, if you are a limited liability company. 11. EMPLOYEES AS INSUREDS The Who Is An Insured provision under SECTION II - LIABILITY COVERAGE is changed by adding the fol- lowing: Any "employee" of yours while using a covered "auto" you don't own, hire or borrow in your business or your personal affairs. This coverage is excess over any other collectible insurance. 12. EMPLOYEE HIRED AUTOS The following is added to the Who Is An Insured Provision: An "employee" of yours is an "insured" while operating an "auto" hired or rented under a contact or agreement in that "employee's" name, with your permission, while performing duties related to the conduct of your business. For purposes of this coverage grant, paragraph 5.b. of the Other Insurance Condition in the Business Auto Coverage Form is replaced by the following: b. For Hired Auto Physical Damage Coverage, the following are deemed to be covered "autos" you own: 1. Any covered "auto" you lease, hire, rent or borrow; and 2. Any covered "auto" hired or rented by your "employee" under a contract in that individual "employ- ee's" name, with your permission, while performing duties related to the conduct of your business. However, any "auto" that is leased, hired, rented or borrowed with a driver is not a covered "auto". This coverage is excess over any other collectible insurance. 13. FELLOW EMPLOYEE EXCLUSION The Fellow Employee exclusion under SECTION II — LIABILITY COVERAGE does not apply if the "bodily injury" results from the use of a covered "auto" you own or hire. This coverage is excess over any other insurance. 14. GLASS REPAIR - WAIVER OF DEDUCTIBLE Under paragraph D. - Deductible - of SECTION III - PHYSICAL DAMAGE COVERAGE, the following is added: No deductible applies to glass damage if the glass is repaired rather than replaced. 15. HIRED AUTO - PHYSICAL DAMAGE COVERAGE If hired "autos" are covered "autos" under SECTION II - LIABILITY COVERAGE and if Comprehensive, Specified Causes of Loss, or Collision coverages are provided under this policy for any "auto" you own, then SECTION III — PHYSICAL DAMAGE COVERAGE is extended to "autos" you hire, subject to the following limit: The most we will pay for "loss" to any hired "auto" is the lesser of: a. $75,000 for "autos" of the private passenger type and $50,000 for all other "autos"; Attachment Code: D548172 Certificate ID: 15775925 DocuSign Envelope ID: 6E13C9AE-FDA6-4FFC-9A43-9693F6FDE454 b. The actual cash value; or c. The cost of repairing or replacing it with other property of like kind or quality. The deductible will be equal to the largest deductible applicable to any owned "auto" for that coverage. No deductible applies to "loss" caused by fire or lightning. Subject to the above limit, deductible and excess provisions, we will provide coverage equal to the broadest coverage applicable to any covered "auto" you own. We will also cover loss of use of the hired "auto" if the following conditions are met: a. It results from an accident; b. You are legally liable; and c. The lessor incurs an actual financial loss. The most we will pay for this loss of use coverage is $1,000 per "accident". 16. LEASE GAP COVERAGE Under paragraph C. Limit of Insurance — of SECTION III — PHYSICAL DAMAGE COVERAGE, the following is added: If a covered "auto" is leased, we will also pay the difference between the actual cash value of a covered "auto" at the time of "loss" and the remaining balance on your lease if the following conditions are met: a. The "auto" has a long term lease and is covered on this policy. b. The lessor is added as an Additional Insured in a written lease agreement. c. You are legally obligated for the remaining balance. We will not pay for any amounts representing excess wear and tear charges; additional mileage charges; taxes; overdue payments; penalties, interest or charges resulting from overdue payments; or lease termination fees. 17. LIABILITY COVERAGE EXTENSIONS — SUPPLEMENTARY PAYMENTS Under SECTION II — LIABILITY COVERAGE, the Coverage Extension for Supplementary Payments is re- vised as follows: a. The limit for the cost of bail bonds is amended to $3,500. b. The limit for reasonable expenses incurred by the "insured" is amended to $500 a day. 18. NEWLY FORMED OR ACQUIRED ORGANIZATIONS a. The Who Is An Insured provision under SECTION II — LIABILITY COVERAGE is amended to include as an "insured" any organization that is formed or acquired by you and over which you maintain majority ownership. b. Paragraph a. of this provision 18. does not apply to any organization: 1. That is a joint venture or partnership; 2. That is an "insured" under any other policy; 3. That has exhausted its Limit of Insurance under any other policy; or 4. 180 days or more after its acquisition or formation by you, unless you have given us notice of the acquisition or formation. c. Paragraph a. of this provision 18. does not apply to "bodily injury" or "property damage" that results from an "accident" that occurred before you formed or acquired the organization. 19. PHYSICAL DAMAGE — TRANSPORTATION EXPENSES COVERAGE Under SECTION III — PHYSICAL DAMAGE Coverage Extensions, the limit for Transportation Expenses is amended to $75 per day and the maximum is amended to $2,250. 20. RENTAL REIMBURSEMENT We will pay for rental reimbursement expenses incurred by you for the rental of an "auto" of the private passenger type because of "loss" to a "covered auto" of the private passenger type. Payment applies in addition to the other- wise applicable amount of each coverage you have on a "covered auto". No deductibles apply to this coverage. We will pay those expenses incurred during the policy period beginning 24 hours after the "loss" and ending, regardless of the policy's expiration, six (6) days after the "loss". Attachment Code: D548172 Certificate ID: 15775925 DocuSign Envelope ID: 6E13C9AE-FDA6-4FFC-9A43-9693F6FDE454 Payment is limited to the lesser of the following amounts: 1. Necessary and actual expenses incurred. 2. The maximum daily payment of $25 for any one day. This coverage does not apply while there are spare or reserve "autos" available to you. If "loss" results from the total theft of the private passenger "auto", we will pay under this coverage only that amount of your rental reimbursement expenses which is not already provided for under the PHYSICAL DAMAGE COVERAGE Extension. 21. TOWING — COVERED AUTOS Under SECTION III — PHYSICAL DAMAGE COVERAGE, Coverage for Towing is amended as follows: a. This coverage applies to any covered "auto" for which a premium charge for towing and labor is shown in the Schedule or in the Declarations. b. The limit is $100. VCA 201 01 09 Includes copyrighted material of Insurance Services Office, Inc. Page 5 of 5 Copyright 2004, OneBeacon Insurance Group LLC Attachment Code: D548172 Certificate ID: 15775925 DocuSign Envelope ID: 6E13C9AE-FDA6-4FFC-9A43-9693F6FDE454 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) The ACORD name and logo are registered marks of ACORD CERTIFICATE OF LIABILITY INSURANCE Lockton Insurance Brokers, LLC 725 S. Figueroa Street, 35th Fl. CA License #0F15767 Los Angeles CA 90017 (213) 689-0065 Prosum, Inc. 2201 Park Pl., Ste. 102 El Segundo CA 90245 PROSU01 Atlantic Specialty Insurance Company 27154 Federal Insurance Company 20281 Hiscox Insurance Company, Inc. 10200 X X 1,000,000 1,000,000 10,000 1,000,000 2,000,000 2,000,000 X . 1,000,000 XXXXXXX XXXXXXX XXXXXXX Comp/Coll Ded 1,000 X X 5,000,000 5,000,000 XXXXXXX Y X 1,000,000 1,000,000 1,000,000 Cyber Technology Prof Liab 3rd Party Crime $5,000,000 Each Wrongful Act $5,000,000 Lim/$25K Ret. $3,000,000 Lim/$10K Ret. A 7110082470012 6/19/2018 6/19/2019 A 7110082470012 6/19/2018 6/19/2019 B 227318518 6/19/2018 6/19/2019 C 8242-9026 6/19/2018 6/19/2019 A 7110082470012 6/19/2018 6/19/2019 A 4060321310009 12/31/2018 12/31/2019 6/19/2019 1302737 Y N Y N N N N 12/12/2018 N N 15775925 15775925 XXXXXXX City of Fort Collins 215 North Mason Street Fort Collins CO 80524 The City of Fort Collins, its officers, agents and employees are named as additional insureds to the extent provided by the policy language and/or endorsement issued by the insurance carrier. X See Attachments DocuSign Envelope ID: 6E13C9AE-FDA6-4FFC-9A43-9693F6FDE454