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HomeMy WebLinkAbout551245 LEIDOS ENGINEERING LLC - INSURANCE CERTIFICATE (7)SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. INSURER(S) AFFORDING COVERAGE INSURER F : INSURER E : INSURER D : INSURER C : INSURER B : INSURER A : NAIC # NAME: CONTACT (A/C, No): FAX E-MAIL ADDRESS: PRODUCER (A/C, No, Ext): PHONE INSURED COVERAGES CERTIFICATE NUMBER:REVISION NUMBER: 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). 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. OTHER: (Per accident) (Ea accident) $ $ N / A SUBR WVD ADDL INSD 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. $ $ $ PROPERTY DAMAGE $ BODILY INJURY (Per accident) BODILY INJURY (Per person) COMBINED SINGLE LIMIT AUTOS ONLY AUTOS ONLY AUTOS NON-OWNED OWNED SCHEDULED ANY AUTO AUTOMOBILE LIABILITY Y / N WORKERS COMPENSATION AND EMPLOYERS' LIABILITY OFFICER/MEMBER EXCLUDED? ACORD 101 (2008/01) The ACORD name and logo are registered marks of ACORD © 2008 ACORD CORPORATION. All rights reserved. THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, FORM NUMBER: FORM TITLE: ADDITIONAL REMARKS ADDITIONAL REMARKS SCHEDULE Page of AGENCY CUSTOMER ID: LOC #: AGENCY CARRIER NAIC CODE POLICY NUMBER NAMED INSURED EFFECTIVE DATE: Leidos Engineering LLC a wholly owned subsidiary of Leidos Holdings, Inc. 11955 Freedom Drive Reston, VA 20190 The City, its officers, agents and employees are included as Additional Insureds as respects to General Liability and Umbrella/Excess Liability. The City, its officers, agents and employees are included as Additional Insureds as respects to Auto Liability where required under contract or agreement. General Liability, Auto Liability and Umbrella/Excess Liability policies shall be Primary and Non-contributory with any other insurance in force for or which may be purchased by Additional Insureds. Waiver of Subrogation applies in favor of Additional Insureds with respects to General Liability, Auto Liability, Umbrella/Excess Liability and Workers Compensation as permitted by law. INSURER AFFORDING COVERAGE: Starr Indemnity & Liability Company NAIC#: 38318 POLICY NUMBER: 1000003172 EFF DATE: 04/01/2018 EXP DATE: 04/01/2019 TYPE OF INSURANCE: LIMIT DESCRIPTION: LIMIT AMOUNT: Workers Comp. & Employers Liab. E.L. Each Accident $3,000,000 (AZ,CT,IA,NJ,NY,NC,TX,VT) E.L. Disease-Pol Lmt $3,000,000 Per Statute E.L. Disease-Each Emp $3,000,000 INSURER AFFORDING COVERAGE: Starr Indemnity & Liability Company NAIC#: 38318 POLICY NUMBER: 1000003173 EFF DATE: 04/01/2018 EXP DATE: 04/01/2019 TYPE OF INSURANCE: LIMIT DESCRIPTION: LIMIT AMOUNT: Workers Compensation E.L. Each Accident $3,000,000 & Employers Liability (WI) E.L. Disease-Pol Lmt $3,000,000 Per Statute E.L. Disease-Each Emp $3,000,000 INSURER AFFORDING COVERAGE: Starr Indemnity & Liability Company NAIC#: 38318 POLICY NUMBER: 1000003174 EFF DATE: 04/01/2018 EXP DATE: 04/01/2019 TYPE OF INSURANCE: LIMIT DESCRIPTION: LIMIT AMOUNT: Workers Compensation E.L. Each Accident $3,000,000 & Employers Liability (AK,MA,FL) E.L. Disease-Pol Lmt $3,000,000 Per Statute E.L. Disease-Each Emp $3,000,000 2 2 Willis of Maryland, Inc. See Page 1 See Page 1 See Page 1 See Page 1 25 Certificate of Liability Insurance SR ID: 16429455 BATCH: 780391 CERT: W6880499 (Mandatory in NH) DESCRIPTION OF OPERATIONS below If yes, describe under ANY PROPRIETOR/PARTNER/EXECUTIVE $ $ $ E.L. DISEASE - POLICY LIMIT E.L. DISEASE - EA EMPLOYEE E.L. EACH ACCIDENT ER OTH- STATUTE PER (MM/DD/YYYY) LIMITS POLICY EXP (MM/DD/YYYY) POLICY EFF LTR TYPE OF INSURANCE POLICY NUMBER INSR DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) EXCESS LIAB UMBRELLA LIAB EACH OCCURRENCE $ AGGREGATE $ $ OCCUR CLAIMS-MADE DED RETENTION $ PRODUCTS - COMP/OP AGG $ GENERAL AGGREGATE $ PERSONAL & ADV INJURY $ MED EXP (Any one person) $ EACH OCCURRENCE $ DAMAGE TO RENTED PREMISES (Ea occurrence) $ COMMERCIAL GENERAL LIABILITY CLAIMS-MADE OCCUR GEN'L AGGREGATE LIMIT APPLIES PER: POLICY PRO- JECT LOC CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DD/YYYY) CANCELLATION AUTHORIZED REPRESENTATIVE ACORD 25 (2016/03) © 1988-2015 ACORD CORPORATION. All rights reserved. CERTIFICATE HOLDER The ACORD name and logo are registered marks of ACORD HIRED AUTOS ONLY Willis of Maryland, Inc. c/o 26 Century Blvd P.O. Box 305191 Nashville, TN 372305191 USA Leidos Engineering LLC a wholly owned subsidiary of Leidos Holdings, Inc. 11955 Freedom Drive Reston, VA 20190 SEE ATTACHED City of Fort Collins Attn: Pat Johnson 700 Wood Street Fort Collins, CO 80521 07/10/2018 1-877-945-7378 1-888-467-2378 certificates@willis.com Starr Indemnity & Liability Company 38318 National Union Fire Insurance Company of P 19445 W6880499 A 1,000,000 1,000,000 10,000 1,000,000 2,000,000 2,000,000 1000100065181 04/01/2018 04/01/2019 A 2,000,000 1000198154181 04/01/2018 04/01/2019 B 25,000,000 28189504 04/01/2018 04/01/2019 25,000,000 A 1000003171 No 3,000,000 04/01/2018 04/01/2019 3,000,000 3,000,000 A Defense Base Act 1000080370 04/01/2018 04/01/2019 Injury by Accident Injury by Disease Injury by Disease SR ID: 16429455 BATCH: 780391 $4M Each Employee $4M Policy Limit $4M Each Accident Page 1 of 2