HomeMy WebLinkAboutCertificate of Liability Insurance 09-07-2007
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CERTIFICATE OF LIAS LITY INSURANCE
[ . ACORD,.
. . _'I PRODUCER
( .. ~~obias Insurance Group, Inc.
;.. ,)247 N. Meridian St. Ste. 300
l\indianapolis IN 46260
Phone: 317-844-7759 Fax:317-844-9910
! 1~SURED' . .....m_"'"'''''''' ....-............
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l bOVERAGES
THE POUCIES 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
i " MAY PERTAIN. THE INSURANCE AFFORDED BY THE POLICIES OESCRIBED HEREIN IS ,SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH
, , POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
I~~~ ~~~g TYPE OF INSURANCE ........-..---- POLICY NUMBER ! PD~i;[gyJ~Jg,wEmrP81!fE'?~~b~;R.ONT.-...-...-.........--. LIMITS
! ' . GE"ERAL LIABILITY i. ~~~~~~~~~~~---....!.~.~-, 0 0 ~Q.OQ
! if\. X: Xi~~MERCIALGENERAL~IABILITY GL0464148402 (07) 03/01/07 03/01/08.PREMISES{EaOCCurence). L~...2..L.o.OO_ ...
il ~ '..~C~IMS MA:~_ !~I::CUR .~;is~:A~~~~~';J~~~~:Ul~~'~~~'~-o.6Q'
I '_ __m ...._..____ GENERAL AGGRE~!",. ._.J~~9_()O ,. ()O 0
..;1 ,.h . GEN.~~~~~I~A IE ~~8; API'.~S ~::: " PRODUCTS" COMP/OP AGG : S 2 , 00 {)_L2 0 0
. AUTOMOBILE LIABILITY [ COMBINED SINGLE LIMIT
, . . [E} " S 1, 000 , 000
~"rl.:.".A X; x ! :::~~:~DAUTOS BAP464148302 (07) 03/01/07 03/01/08 a accident
BODILY INJURY
~ SCHEDULED AUTOS (Per person)
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DESCRIPTION OF OPERATIONS / LOCATIONS J VEHICLES / EXCLUSIONS ADDED BY ENpORSEMENT J SPECIAL PROVISIONS
~:.;DDITIONAL INSURED [GENERAL LIABILITY & f\.U~OMOBILE LIABILITY] SEE
I !l\.TTACHED - RE: RIVERPORT NO. 2 PUMP STATION & FORCE MA.IN UPGRADES
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OP ID C21 DATe (MMIDDIYYYY)
MITCH 0 "I 09/07/07
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
Mitchell & stark Construction
Company, Inc.
P. O. Box 219
Medora IN 47260
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._..._..___........L!~~URERS AFFORDING COVERAGE
! I~.~,~~~~~,~___ Zurich Ama~ic;an Ins. Company
l'l..!NSURER~.:__.._..~..:.h Specialty Insurance Co.
INSURER C:
u... _n_."" _.,.. ....,._..~._... ......'.
ilNSURER D;
i INSURER E;
.___.L~ 119~..
NAIC#
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---..---.-.-.-----... ..
x . HIRED AUTOS
X NON.OWNED AUTOS
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,-----...--.....--
BOOIL Y INJURY I
(Per accident) i S
...-------.--...\...---.--.....-.---
PROPERTY DAMAGE
(Per accident)
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GARAGE LIABILITY
ANY AUTO
I AUTO ONLY. EA ACCIDENT .~~---- ..
j OTHER THAN EA ACe! S .. ...
i AUTO ONLY: AGG : $
i ~GH OCCURR~C?~ S~J.o 09.,.0 0 0
i AGGREGATE __lS.?,.9.<!.(),.Q.o(),..
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. EXCESS/UMBRELLA LIABILITY
\ . j CLAIMS MADE
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! ULP000476302 (07)
03/01/07
03/01/08
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OCCUR
. DEDUCTIBLE
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. :l{.iI91'..Y.b.ltAl!..~.L._.LE;.~~!._._n_... .- -------
E.L EACH ACCIDENT j $ 1,000,000
E.~:';;~S'~SE:'~ EMPLOY;E['S'Tooo-;oo-O
E:~~;:;ISEASE " POLICY LIMIT i S 1, () 0 6 , 000---
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'X ; RETENTION s10,OOO
, WORKERS COMPENSATION AND
; EMPLOYERS' LIABILITY
; ANY PROPRIETOR/PARTNER/EXECUTIVE
: OFFICER/MEMBER EXCLUDED?
: If yes. describe under
. SPECIAL PROVISIONS below
OTHER
WC464148502(07)
03/01/07
03/01/08
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CERTIFICATE HOLDER
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CANCELLATION
JEIi'F-05
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES Be CANCELLeD BEFORE THE EXPIRATION
DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL ~ DAYS WRITTEN
NOTice TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL
IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR
RePRESENTATIVES.
~ ~COROCORPORATION1988
CITY OF JEFFERSONVILLE
501 EAST COURT AVENUE
JEFFERSONVILLE IN 47130
if (\CORD 25 (2001/06)
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PAGE 2
DATE 09/07/07
: OT PAD MITCH-O
: N E : INSURED'S NAME M:i. tchell & Stark Construction OP 10 C2
IIF YOU ARE THE RECIPIENT OF THIS CERTIFICATE:
. ,ANY WORDING TO INCLUDE THE HOLDER AS AN ADDITIONAL INSURED r PROVIDE
,)COVERAGE ON A PRIMARY AND NON-CONTRIBUTORY BASIS, OR PROVIDE A WAIVER OF
~ [SUBROGATION APPLIES ONLY WHERE REQUIRED BY' WRITTEN CONTRACT OR AGREEMENT
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1 [i. IF YOU ARE THE REQUESTOR TO PROVIDE THIS C,ERTIFICATE:
Tobias Insurance GrouPr Inc. hasr upon your requestr issued the attached
f,certificate of Insurance.
tlIf you did not already, we highly recommend that you provide our Agency
IWith a copy of the insurance and indemnification provisions of the
. ,contract pertaining to the certificate request so that we may properly
j 'ascertain whether your insurance program addresses the termsr types and
j ..amounts of insurance coverage referenced by the contract.
"While most certificates can be issued at no cost to your the contract may
IT 'identify insurance requirements that require the purchase of insurance
~ ~coverage at an additional premium. In some instancesr the coverage
~['identified in the contract may be outside the underwriting guidelines of
the insurance carrier and cannot be obtained. In other instancesr you may
r;...not wish to purchase the additional coverage and may attempt to negotiate
,;changes in the insurance requirements.
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frIn performing the review of your contractsr neither Tobias Insurance
Li Group r Inc. nor its employees are providing legal advice or a legal
[opinion concerning any portion of the contract. Our Agency is not
. undertaking to identify all potential liaqility that might arise under
! Bthis contract. This review is provided for your information and should
t i'not be relied upon by third parties.
fAnY description of insurance coverage is subject to the termsr conditionsr
rrexclusions and other provisions of the policies and any applicable
llregulations, rating rules or plans.
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PAGE 3
DATE 09/07/07
iNOTEPAD: ~~~~;O~:ME ~;~h~i~ & Stark Construction ;II~C~;O
rADDITIONAL INSURED [GENERAL LIABILITY & AU~OMOBILE LIABILITY]: CITY OF
,JEFFERSONVILLE INDIANA, STRAND ASSOCIATES, INC.; ENVIRONMENTAL MANAGEMENT
, [CORPORATION, INDIANA PORT COMMISSION AND ANY OTHER CONTRACTUALLY REQUIRED
l .l~ENTITIES BUT ONLY WITH RESPECT TO WORK PERJ1'ORMED ON THEIR BEHALF BY OR FOR
THE NAMED INSURED. .
[iTHE ADDITIONAL INSURED STATUS GRANTED TO THE ADDITIONAL INSUREDS ON THE
I \GENERAL LIABILITY COVERAGE APPLIES TO ONGOfNG AND COMPLETED OPERATIONS, IF
IREQUIRED BY WRITTEN CONTRACT OR WRITTEN AGREEMENT - THE GENERAL LIABILITY
& AUTOMOBILE LIABILITY COVERAGES WILL APPLY ON A PRIMARY &
f jNON-CONTRIBUTORY BASIS IN FAVOR OF THE ADD+TIONAL INSUREDS, IF REQUIRED BY
1 IWRITTEN CONTRACT OR WRITTEN AGREEMENT.
ITHE UMBRELLA COVERAGE IS "FOLLOW FORM".
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i 'THE INSURANCE COMPANY{IES) WILL MAIL 30 DAYS NOTICE OF CANCELLATION EXCEPT
i ('FOR NON-PAYMENT OF PREMIUM AT WHICH TIME, 10 DAYS NOTICE WILL BE GIVEN,
SUBJECT TO THE TERMS AND CONDITIONS OF THE POLICIES THEMSELVES.
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