20_21_LIAC_AUTC_WCMC_XLIC_w-_AI_-_Insurance_Spencer_Const.pdf

PDF 723 KB Posted

Attached to
Master Agreement AZ|CTR055131
Contract number
CTR055131
Issued by
Arizona

About this file

This document is a comprehensive insurance certificate and policy package for Spencer Construction LLC, based in Tucson, Arizona, issued by multiple insurance providers including Third Coast Insurance Company, Allied Insurance Company of America, StarStone Specialty Insurance Company, Berkshire Hathaway Homestate Insurance Company, and Scottsdale Indemnity Company. The certificate is specifically related to insurance coverage for the State of Arizona Game and Fish Department, with the policy effective from March 2, 2020 to June 1, 2021, covering various liability aspects including commercial general liability, automobile liability, workers' compensation, and excess liability.

The insurance package provides coverage with substantial liability limits, including a $1,000,000 per occurrence general liability limit, a $1,000,000 automobile liability limit, a $3,000,000 umbrella liability limit, and workers' compensation coverage. The policies include additional insured provisions for the State of Arizona Game and Fish Department, with specific endorsements for ongoing operations, completed operations, and leased equipment. The coverage is comprehensive, addressing potential risks such as bodily injury, property damage, personal and advertising injury, and includes provisions for rental reimbursement, emergency lockout services, and protection for hired and non-owned vehicles. The policy also includes waivers of subrogation and is primary and non-contributory in nature, ensuring broad protection for both Spencer Construction and the state agency.

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ANY PROPRIETOR/PARTNER/EXECUTIVE

OFFICER/MEMBER EXCLUDED?

INSR ADDL SUBR

LTR INSD WVD

PRODUCER CONTACT

NAME:

FAXPHONE

(A/C, No):(A/C, No, Ext):

E-MAIL

ADDRESS:

INSURER A :

INSURED INSURER B :

INSURER C :

INSURER D :

INSURER E :

INSURER F :

POLICY NUMBER POLICY EFF POLICY EXPTYPE OF INSURANCE LIMITS(MM/DD/YYYY) (MM/DD/YYYY)

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 RENTEDCLAIMS-MADE OCCUR $PREMISES (Ea occurrence)

MED EXP (Any one person) $

PERSONAL & ADV INJURY $

GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $

PRO-POLICY LOC PRODUCTS - COMP/OP AGGJECT

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

E.L. DISEASE - POLICY LIMITDESCRIPTION OF OPERATIONS below

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

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)

CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DD/YYYY)

The ACORD name and logo are registered marks of ACORD

5/7/2021

(520) 467-6054 (520) 467-6093

10713

Spencer Contruction LLC 10132 N Oracle Road Ste. 160 Tucson, AZ 85704

10127 44776 20044 15580

A 1,000,000

X X GLVEN0101120 3/2/2020 6/1/2021 500,000

$10,000 BI/PD Ded 10,000 Per Occurrence 1,000,000

2,000,000 2,000,000

1,000,000B

X X ACPBAL3110067770 3/2/2021 6/1/2021

3,000,000C

U88798200ALI 3/2/2020 6/1/2021 3,000,000

D

X SPWC245517 3/2/2021 3/2/2022 1,000,000

Y 1,000,000 1,000,000

E Excess Liab over XLI0005237 3/2/2020 Per Occurrence 4,000,000 E over $3,000,000 XLI0005237 3/2/2020 6/1/2021 Aggregate 4,000,000

Solicitation No BPM003283 General Liability: Additional Insured, CG2010 04-13, Additional Insured Completed Operations CG203704-13, Additional Insured Lessor of Leased Equipment CG2034 04-13, Waiver of Transfer of Rights of Recovery Against Others CG2404 05-09, Primary Noncontributory-Other Insurance Conditions CG2001 04-13;

Auto Liability: Additional Insured, Waiver of Subrogation, Primary & Non-Contributory AC7005 03-16 Workers Compensation: Excluded: Lindsey Spencer; Waiver of Subrogation WC990410C 01-19, WC000313 04-84

State of Arizona Game and Fish Department Purchasing Office 5000 West Carefree Highway Phoenix, AZ 85086

SPENCON-02 CATHYDAMSTRALEPLEY

NFP Property & Casualty Services, Inc.

6992 East Broadway Boulevard Tucson, AZ 85710

Cathy Damstra-Lepley cathy.damstra-lepley@nfp.com

Third Coast Insurance Company Allied Insurance Company of America StarStone Specialty Insurance Company Berkshire Hathaway Homestate Insurance Company

Scottsdale Indemnity Company

X

6/1/2021

X X

X X

XX

X

X X

POLICY NUMBER: COMMERCIAL GENERAL LIABILITY

CG 20 10 04 13

THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.

CG 20 10 04 13 © Insurance Services Office, Inc., 2012 Page 1 of 2

ADDITIONAL INSURED – OWNERS, LESSEES OR

CONTRACTORS – SCHEDULED 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) Location(s) Of Covered Operations

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:

1. Your acts or omissions; or

2. The acts or omissions of those acting on your behalf;

in the performance of your ongoing operations for the additional insured(s) at the location(s) designated above.

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 additional exclusions apply:

This insurance does not apply to "bodily injury" or "property damage" occurring after:

1. All work, including materials, parts or equipment furnished in connection with such work, on the project (other than service, maintenance or repairs) to be performed by or on behalf of the additional insured(s) at the location of the covered operations has been completed; or

2. That portion of "your work" out of which the injury or damage arises has been put to its intended use by any person or organization other than another contractor or subcontractor engaged in performing operations for a principal as a part of the same project.

GLVEN0101120

BLANKET AS REQUIRED BY WRITTEN CONTRACT

Page 2 of 2 © Insurance Services Office, Inc., 2012 CG 20 10 04 13

C. 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 37 04 13

THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.

CG 20 37 04 13 © Insurance Services Office, Inc., 2012 Page 1 of 1

ADDITIONAL INSURED – OWNERS, LESSEES OR

CONTRACTORS – COMPLETED OPERATIONS

This endorsement modifies insurance provided under the following:

COMMERCIAL GENERAL LIABILITY COVERAGE PART

PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE PART

SCHEDULE

Name Of Additional Insured Person(s) Or Organization(s) Location And Description Of Completed Operations

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" or "property damage" caused, in whole or in part, by "your work" at the location designated and described in the Schedule of this endorsement performed for that additional insured and included in the "products-completed operations hazard".

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.

GLVEN0101120

BLANKET AS REQUIRED BY VIRTUE OF WRITTEN

CONTRACT

CG 24 04 05 09

CG 24 04 05 09 © Insurance Services Office, Inc., 2008 Page 1 of 1

WAIVER OF TRANSFER OF RIGHTS OF RECOVERY

AGAINST OTHERS TO US

This endorsement modifies insurance provided under the following:

COMMERCIAL GENERAL LIABILITY COVERAGE PART

PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE PART

SCHEDULE

Name Of Person Or Organization:

Information required to complete this Schedule, if not shown above, will be shown in the Declarations.

The following is added to Paragraph 8. Transfer Of Rights Of Recovery Against Others To Us of Section IV – Conditions:

We waive any right of recovery we may have against the person or organization shown in the Schedule above because of payments we make for injury or damage arising out of your ongoing operations or "your work" done under a contract with that person or organization and included in the "products-completed operations hazard". This waiver applies only to the person or organization shown in the Schedule above.

BLANKET AS REQUIRED BY VIRTUE OF A VALID WRITTEN CONTRACT

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WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY

WC 99 04 10 C

(Ed. 01-19)

WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT-CALIFORNIA

BLANKET BASIS

We have the right to recover our payments from anyone liable for an injury covered by this policy. We will not enforce our right against the person or organization named in the Schedule. (This agreement applies only to the extent that you perform work under a written contract that requires you to obtain this agreement from us.)

The additional premium for this endorsement shall be calculated by applying a factor of 2% to the total manual premium, with a minimum initial charge of $350, then applying all other pricing factors for the policy to th is calculated charge to derive the final cost of this endorsement.

This agreement shall not operate directly or indirectly to benefit anyone not named in the Schedule.

Schedule

Blanket Waiver

Person/Organization

Blanket Waiver – Any person or organization for whom the Named Insured has agreed by written contract to furnish this waiver.

This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated.

(The information below is required only when this endorsement is issued subsequent to preparation of the policy.)

Endorsement No.:

Premium $

WC 99 04 10 C

Countersigned by ______________________________________

(Ed. 01-19)

Job Description

Insurance Company: Berkshire Hathaway Homestate Insurance Company

Waiver Premium (prior to adjustments)

Endorsement Effective: 03-02-2020 Policy No.:SPWC140012

Insured: Spencer Construction, llc

WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 00 03 13

(Ed. 4-84)

WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT

We have the right to recover our payments from anyone liable for an injury covered by this policy. We will not enforce our right against the person or organization named in the Schedule. (This agreement applies only to the extent that you perform work under a written contract that requires you to obtain this agreement from us.)

This agreement shall not operate directly or indirectly to benefit anyone not named in the Schedule.

Schedule

This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated.

(The information below is required only when this endorsement is issued subsequent to preparation of the policy.)

Endorsement Effective Policy No. Endorsement No.

Insured Premium

Insurance Company Countersigned by___________________________________________

WC 00 03 13

(Ed. 4-84)

1983 National Council on Compensation Insurance.

cathy-damstra Typewriter Blanket Waiver–Any person or organization for whom the Named Insured has agreed by written contract to furnish this waiver.

cathy-damstra_1 Typewriter

SPWC140012

cathy-damstra_2 Typewriter Berkshire Hathaway Homestate Insurance Company cathy-damstra_3 Typewriter Spencer Construction LLC

File details come from the government source that posted it. Updated .