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HomeMy WebLinkAbout413403 OTAK INC - INSURANCE CERTIFICATE (13)Arm/ �® CERTIFICATE OF LIABILITY INSURANCE DATE (MMIDD/YYYY) `�VR 12/18,2017 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 Peggy MacMillan NAME: JD Fulwiler & Co. Insurance, Inc. PpHONr o (503)293-8325 A/� (503)293-5418 Ext : No): 5727 SW Macadam Ave E-MAIL pmacmillan@jdfulwiler.com ADDRESS: �) PO BOX 69508 INSURER(S) AFFORDING COVERAGE NAIC # Portland OR 97239 INSURER A : Travelers Indemnity Cc of CT 25682 INSURED INSURER B : Travelers Indemnity Co of Am 25666 Otak Inc. INSURER C : Zurich American Insurance Cc 808 SW 3rd Ave Ste 300 INSURER D : INSURER E : Portland OR 97204 INSURER F : COVERAGES CERTIFICATE NUMBER: 18/19 Gen Use REVISION NUMBER: 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. ILTR TYPE OF INSURANCE INSD WVD POLICY NUMBER POLICY Y EFF (MM/DDIYYW) POLICY XP (MM/DD/YYYY) LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS -MADE OCCUR PREMISES Ea occurrence $ 300,000 ME EXP (Any one person) $ 5,000 PERSONAL & ADV INJURY $ 1,000,000 A 6805H242469 01/01/2018 01/01/2019 GEN'L AGGREGATE LIMIT APPLIES PER. PRO- POLICY PRO- rX LOC JECT GENERAL AGGREGATE $ 2,000,000 PRODUCTS - COMP/OP AGG S 2,000,000 Employee Benefits s 1,000,000 OTHER: AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea accident s 1,000,000 X BODILY INJURY (Per person) $ ANY AUTO A OWNED SCHEDULED AUTOS ONLY AUTOS BA1502P892 01/01/2018 01/01/2019 BODILY INJURY (Pe accident) $ HIRED NON -OWNED AUTOS ONLY AUTOS ONLY IX X PROPERTY DAMAGE Per accident $ Towing $ X UMBRELLA LIAB 1 X OCCUR EACH OCCURRENCE $ 10,000,000 AGGREGATE $ 10,000,000 B EXCESS LIAB CLAIMS -MADE CUP5C857081 01/01/2018 01/01/2019 DED I X RETENTION $ 10,000 S WORKERS COMPENSATION PER OTH- X C AND EMPLOYERS' LIABILITY YIN ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? ❑ (Mandatory in NH) NIA WC9696241 01/01/2018 01/01/2019 STATUTE ER E.L. EACH ACCIDENT $ 1,000,000 E.L. DISEASE - EA EMPLOYEE S 1,000,000 If yes, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT $ 1,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) The City, its officers, agents and employees are ncluded as additional insureds on the general and auto liability with regard to operations of the named insured subject to policy terms, conditions and exclusions per attached form CGD381 & ; Cancellation provisions apply per attached form ILT40503 GANGtLLA I IUN SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN City of Fort Collins ACCORDANCE WITH THE POLICY PROVISIONS. PO Box 580 AUTHORIZED REPRESENTATIVE Fort Collins CO 80522 �c \ ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD F Additional Named Insureds Other Named Insureds Day CPM LLC, an OTAK Division HLB Otak Inc., an Oregon Corporation Loris and Associates Inc, an OTAK Division JOTAK Architects Inc, a Washington Corporation �Otak Architects Inc., an Oregon Corporation 10tak Engineering, Inc., an Oregon Corporation 10tak International (Caymen Islands) 10tak Nevada, LLC, an Oregon Limited Liability Co 10tak, Inc. 401K Employee Savings Plan 10tak, Inc., a Colorado Corporation 10tak, Inc., an Washington Corporation OFAPPINF (02/2007) COPYRIGHT 2007, AMS SERVICES INC