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HomeMy WebLinkAbout413403 OTAK INC - INSURANCE CERTIFICATE (9)The ACORD name and logo are registered marks of ACORD CERTIFICATE HOLDER © 1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25 (2014/01) AUTHORIZED REPRESENTATIVE CANCELLATION CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DD/YYYY) JECT LOC POLICY PRO- GEN'L AGGREGATE LIMIT APPLIES PER: CLAIMS-MADE OCCUR COMMERCIAL GENERAL LIABILITY PREMISES (Ea occurrence) $ DAMAGE TO RENTED EACH OCCURRENCE $ MED EXP (Any one person) $ PERSONAL & ADV INJURY $ GENERAL AGGREGATE $ PRODUCTS - COMP/OP AGG $ DED RETENTION $ CLAIMS-MADE OCCUR $ AGGREGATE $ UMBRELLA LIAB EACH OCCURRENCE $ EXCESS LIAB DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) INSR LTR TYPE OF INSURANCE POLICY NUMBER POLICY EFF (MM/DD/YYYY) POLICY EXP (MM/DD/YYYY) LIMITS PER STATUTE OTH- ER E.L. EACH ACCIDENT E.L. DISEASE - EA EMPLOYEE E.L. DISEASE - POLICY LIMIT $ $ $ ANY PROPRIETOR/PARTNER/EXECUTIVE If yes, describe under DESCRIPTION OF OPERATIONS below (Mandatory in NH) OFFICER/MEMBER EXCLUDED? WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y / N AUTOMOBILE LIABILITY ANY AUTO ALL OWNED SCHEDULED HIRED AUTOS NON-OWNED AUTOS AUTOS AUTOS COMBINED SINGLE LIMIT BODILY INJURY (Per person) BODILY INJURY (Per accident) Additional Named Insureds Other Named Insureds OFAPPINF (02/2007) COPYRIGHT 2007, AMS SERVICES INC HLB Otak Inc., an Oregon Corporation OTAK Architects Inc, a Washington Corporation Otak Architects Inc., an Oregon Corporation Otak Engineering, Inc., an Oregon Corporation Otak International (Caymen Islands) Otak Nevada, LLC, an Oregon Limited Liability Co Otak, Inc. 401K Employee Savings Plan Otak, Inc., a Colorado Corporation Otak, Inc., an Washington Corporation PROPERTY DAMAGE $ $ $ $ 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. INSD ADDL WVD SUBR N / A $ $ (Ea accident) (Per accident) OTHER: 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). COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: INSURED PHONE (A/C, No, Ext): PRODUCER ADDRESS: E-MAIL FAX (A/C, No): CONTACT NAME: NAIC # INSURER A : INSURER B : INSURER C : INSURER D : INSURER E : INSURER F : INSURER(S) AFFORDING COVERAGE SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. INS025 (201401) 3/20/2017 JD Fulwiler & Co. Insurance, Inc. 5727 SW Macadam Ave PO Box 69508 Portland OR 97239 Peggy MacMillan (503)293-8325 (503)293-5418 pmacmillan@jdfulwiler.com Otak Inc. 808 SW 3rd Ave Ste 300 Portland OR 97204 Travelers Indemnity Co of CT 25682 Travelers Indemnity Co of Am 25666 Zurich American Insurance Co Beazley Insurance Company Inc 17/18 AZ CO Gen Use A X X X X 6805H242469 12/9/2016 1/1/2018 1,000,000 300,000 5,000 1,000,000 2,000,000 2,000,000 Employee Benefits 1,000,000 A X BA1502P892 12/9/2016 1/1/2018 1,000,000 Towing B X X 10,000 CUP5C8570811247 12/9/2016 1/1/2018 10,000,000 10,000,000 C ARIXONA & COLORADO WC9696241 4/1/2016 4/1/2017 X 1,000,000 1,000,000 1,000,000 D A&E Prof'l W/Pollution V10267160801 12/9/2016 1/1/2018 Limits per Claim/Agg/ $2m/$4m Deductible Certificate holder is included as an additional insured on the General Liability and Auto Liability with regards to operations of the named insured subject to policy terms, conditions and exclusions. P MacMillan/TMAYDA City of Fort Collins Attn: Purchasing Dept PO Box 580 Fort Collins, CO 80522 bdiven@fcgov.com