HomeMy WebLinkAboutCertificate of Liability Insurance 8/3/2007
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A CORD_ CERTIFICATE OF LIABILITY INSURANCE OP 10 C21 DATE (MMIDD/YYYY)
i MITCH-O 08/03/07
'I ~ROD~CER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
! !:obl.as Insurance Group, Inc. HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
i :.1247 N. Meridian st. Ste. 300 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
'l.Indianapolis IN 46260
!"hone:3l7-844-7759 Fax:317-844-9910 INSURERS AFFORDING COVERAGE NAlC#
f,SURED INSURER A: Zurich 1lmsrican :Ins. company
I: INSURER B: A%'ch Special ty :Insurance Co.. 21199
Mitchell &. Stark Construction INSURER c:
comgan~, Inc.
P. . ox 219 INSURER D:
Medora IN 47260
INSURER E:
,
COVERAGES
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J . 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
II ' POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.:
r~TR NSR[ TYPE OF INSURANCE POUCY NUMBER DATE IMMIDDIYY1- DATE IMMIDD/YY\ LIMITS
! : GENERAL !.lABILITY EACH OCCURRENCE $1,000,000
i; -
l ;A X ~ COMMERCIAL GENERAL LIABILITY GL0464148402(07} 03/01/07 03/01/0B PREMISES (Ea occ~r:;nce) $300,000
L - ~ CLAIMS MADE [!] OCCUR MED EXP (Anyone person) $10,000
J t PERSONAL & ADV INJURY $1,000,000
I' -
, . GENERAL AGGREGATE $2,000,000
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~N'L AGGRErifl LIMIT APPLIES PER: PRODUCTS-COM~OPAGG $2,000,000
POLICY X rr8i n LOC
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, AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT
II 'A - $1,000,000
X ~ ANY AUTO BAP464148302(07} 03/01/07 03/01/08 (Ea accident)
- ALL OWNED AUTOS BODILY INJURY
~ ;- SCHEDULED AUTOS (Per person) $
II; -
~ HIRED AUTOS BODILY INJURY
~ NON-DWNED AUTOS (Per accident) $
j" - PROPERTY DAMAGE $
!r~ (Per accident)
GARAGE LIABILITY AUTO ONLY - EA ACCIDENT $
==i ANY AUTO OTHER THAN EA ACC $
~ ~ AUTO ONLY:
~ ~ AGG $
l:B EXCESSIUMBRELLA LIABILITY i EACH OCCURRENCE $5,000,000
~ OCCUR D CLAIMS MAOE f ULP000476302 (07), 03/01/07 03/01/08
AGGREGATE $5,000,000
1 : $
l1 ~ DEDUCTIBLE $
X RETENTION $10,000 $
! ? WORKERS COMPENSATION AND X ITORY LIMITS I I()~~-
., ~ EMPLOYERS' LIABILITY WC464148502(07) 03/01/07 03/01/08 $1,000,000
l~' ANY PROPRIETOR/PARTNER/EXECUTIVE E.L. EACH ACCIDENT
OFFICER/MEMBER EXCLUDED? E.L. DISEASE - EA EMPLOYEE $1,000,000
~t~Mt"~~~Yi~f6~s below E.L. DISEASE - POLICY LIMIT $1,000,000
~ ~ OTHER
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(~ESCRIPTION OF OPERATIONS I LOCATIONS 'VEHICLES 'EXCLUSIONS ADDED BY ENPORSEMENT' SPECIAL PROVISIONS
i\f\DDITIONAL INSURED[GENERAL LIABILITY & AUT9MOBILE LIABILITY]: CITY OF
rJEFFERSONVILLE INDIANA, STRAND ASSOCIATES,. INC.; ENVIRONMENTAL MANAGEMENT
~ORPORATION AND ANY OTHER CONTRACTUALLY RE9UIRED ENTITIES BUT ONLY WITH
!l~ESPECT TO WORK PERFORMED ON THEIR BEHALF ~Y OR FOR THE NAMED INSURED. - SEE
~&TTACHED - RE: RIVERPORT NO. 2 PUMP STATIO~ & FORCE MAIN UPGRADES
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I !~CORD 25 (2001/08)
Lili
CITY OF JEFFERSONVILLE
501 EAST COURT AVENUE
JEFFERSONVILLE IN 47130
CANCELLATION
JEFF _ 0 5 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCt':LLED BEFORE THE EXPIRATION
DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL ~ DAYS WRmEN
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
CERTIFICATE HOLDER
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CORD CORPORATION 1988
I';"":;{'
r,,~Y~g~:G T~~ INCLUDE THE HOLDER AS AN AD~ITIONAL INSURED, PROVIDE
. i iCOVERAGE 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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lr'IF ~OU ARE THE REQUESTOR TO PROVIDE THIS C~RTIFlCATE:
Tob1as Insurance Group, Inc. has, upon your request, issued the attached
r 1Certificate of Insurance.
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~'['If you did not already, we highly recommenli that you provide our Agency
with a copy of the insurance and indemnifipation provisions of the
f;ccontract pertaining to the certificate request so that we may properly
1 iascertain whether your insurance program addresses the terms, types and
1 r!'amounts of insurance coverage referenced by the contract.
r~While most certificates can be issued at np cost to you, the contract may
~ 'identify insurance requirements that require the purchase of insurance
t~coverage at an additional premium. In som~ instances, the coverage
lidentified in the contract may be outside the underwriting guidelines of
r--.the i~surance carrier and ca~~t be obtain~d. In other instances, you.may
'not w1sh to purchase the add1t1onal coverage and may attempt to negot1ate
'i\changes in the insurance requirements.
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l (,In performing the review of your contracts, neither Tobias Insurance
"fGroup, Inc. nor its employees are prOViding, legal advice or a legal
opinion concerning any portion of the contract. Our Agency is not
rBundertaking to identify all potential liability that might arise under
jHthis contract. This review is provided fo~ your information and should
t, r"not be relied upon by third parties.
,;Any description of insurance coverage is subject to the terms, conditions,
I ,'exclusions and other provisions of the policies and any applicable
t;]regulations, rating rules or plans.
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rr;HE ADDITIONAL INSURED STATUS GRANTED TO THE ADDITIONAL INSUREDS ON THE
. .:GENERAL LIABILITY COVERAGE APPLIES TO ONGOING AND COMPLETED OPERATIONS, IF
. r jREQUIRED BY WRITTEN CONTRACT OR WRITTEN AG~EEMENT. THE GENERAL LIABILITY
l..('&: AUTOMOBILE LIABILITY COVERAGES WILL APPLY ON A PRIMARY &:
NON-CONTRIBUTORY BASIS IN FAVOR OF THE ADD~TIONAL INSUREDS, IF REQUIRED BY
f ,WRITTEN CONTRACT OR WRITTEN AGREEMENT.
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l f;THE UMBRELLA COVERAGE IS "FOLLOW FORM".
"THE INSURANCE COMPANY{IES) WILL MAIL 30 DAYS NOTICE OF CANCELLATION EXCEPT
1 !FOR NON-PAYMENT OF PREMIUM AT WHICH TIME, 10 DAYS NOTICE WILL BE GIVEN,
! lSUBJECT TO THE TERMS AND CONDITIONS OF THE POLICIES THEMSELVES.
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Additional Insured - Auto~atic - Owners, Lessees Or
Contractors - Broad Form
Policy No. Err. Date of PoL Expo Date of l>oL Err. Date or End. Producer Add'L ITem Return Prem.
GLD464148402 S $
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
This endorsement modifies insurance provided und<;:r the:
Commercial General Liability Coverage Part
A. WHO IS AN INSURED (Section II) is amended to include as an insured any person or organization whom you are re-
quired to add as an additional insured on this policy under a written contract or written agreement.
B. The insurance provided to additional insureds applies only to "bodily injury", "property damage" or "personal and adver-
tising injury" covered under Section I, Coverage A, BODILY INJURY AND PROPERTY DAMAGE LIABILITY and
Coverage B, PERSONAL .~"ID ADVERTlS1NG INJURY LIABILITY, but only if:
1. The "bodily injury" or "property damage" results from your negligence; and
2. The ''bodily injury", "property damage" or "personal and advertising injury" results directly from:
a. Your ongoing operations; or
b. "Your work" coroplet,~d as included in the "products-completed operations hazard",
performed for the additional insured, which is the subject of the written contract or written agreement.
C. However, regardless of the provisions of paragraphs A. and B. above:
1. We will not extend any insurance coverage to any additional insured person or organization:
a. That is not provided to you in this policy; or
b. That is any broader (:overage than ydu are required to provide to the additional insured person or organization
in the written contract or written agreement; and
2. We will not provide Limits of Insurance to any additional insured person or organization that exceed the lower of:
a. The Limits of Insurance provided to you in this policy; or
b. The Limits of Insurance you are required to provide in the written contract or written agreement.
D. The insurance provided to the additional insured person or organization does not apply to:
1. "Bodily injury", "property damage" or "p~rsonal and advertising injury" that results solely from negligence of the ad-
ditional insured; or
U-GL-117S-A CW (9/&3)
Page 1 orz
Includes copyrighted malerial of Insurance Services Omce. Inc. with its permission.
AGENT COPY
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2. "Bodily injury", "property d~age" or "personal and advertising injury" aris~ng aut of the rendering or failure to
render any professianal architectural, engineering or surveying services including:
a. The preparing, approving, or failing to prepare or approve maps, shop drawings. opinians, reports, surveys,
field arders, change arders .or drawings and specificatians; and
b. Supervisory, inspection, architectural ar engineering activities.
E. The additianal insured must see to it that:
1. We are natified as soan as practicable of an .occjlrrence" ar offense that may result in a claim:
2. We receive written notice af a daim or "suit" as ~oon as practicable; and
3. A request far defense and indemnity of the claim or "suitH will pramptly be brought against any policy issued by
another insurer under which the additional insurcrd also has rights as an insured or additional insured.
F. The insurance provided by this endorsement is primary insurance and we will not seek colltri.bntion from any ather
insurance available to any additional insured person. or organization unless the other insurance is provided by a con-
tractor other than you for the same operations and job location. Then we will share with that other insurance by the
method described in paragraph 4.c. of SECTION IV,- COMMERCIAL GENERAL LIABILITY CONDITIONS.
Any provisions in this Coverage Part not changed by the terms and conditions of this endorsement continue to apply as
written.
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U-GlA175-A CW (9/03)
Page 2 of2
, AGENT COPY
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THIS BINDER IS A TEMPORARY INSURANCE CONTRACT, SUBJECt TO THE CONDITIONS SHOWN ON THE REVERSE SIDE OF THIS FORM.
'~GENCY COMPANY B1NDERtJ 12819
, Zurich American Ins. Company
INSURANCE BINDER
OP ID C2
DATE (MMlDD/YYYY)
08/03/2007
DATE
EFFECTIVE
DATE
TIME
X 12:01 AM
NOON
AM
PM
OS/lS/08
(NC,NO):
CODE: SUB CODE:
! ;:USTOMERID: MITCH-O
i "~SURED
11: City of Jeffersonville Indiana
(SEE BINDER ADDENDUM ATTACHED)
, . 501 E. Court Avenue
, ' Jeffersonville IN 47130
THIS BINDER IS ISSUED TO EXTEND COVERAGE IN THE ABOVE NAMED COMPANY
PER EXPIRING POl.ICY #: OCP 9 261380
DESCRIPTION OF OPERATIONSNEHICLESIPROPERTY (Including local1on)
Near Intersection of utica Pike and Port
Road, Jeffersonville, IN - Contract 1-2007
- Riverport No. 2 Pump station & Force Main
Upgrades
COVERAGES
liMITS
f '-:: TYPE OF INSURANce COVERAGE/FORMS DEDUCTIBLE ColNS% AMOUNT
I;
I ;'ROPERTY CAUSES OF LOSS
];= BASIC D BROAD D SPEC
!f-
}=ERAL LIABILITY EACH OCCURRENCE $5,000,000
" ,_ COMMERCIAL GENERAL LIABIUTY RENTED PREMISES $
J: tJ CLAIMS MADE 0 OCCUR MED EXP (Anyone person) $
1'-
~t Owner" Contractor Proto PERSONAL & ADV INJURY $
GENERAL AGGREGATE $5,000,000
tj l;' RErRO DATE FOR CLAIMS MADE: PRODUCTS - COMP/OP AGG $
t .:
~ ;,UTOMOBILE LIABILITY COMBINED SINGlE LIMIT $
..li- ANY AUTO BODILY INJURY (Per person) $
\ . I ALL OWNED AUTOS BODILY INJURY (Per accident) $
'-
,,,- SCHEDULED AUTOS PROPERTY DAMAGE $
~t HIRED AUTOS MEDICAL PAYMENTS $
NON-OWNED AUTOS PERSONAL INJURY PROT $
~ ,
Ji;- UNINSURED MOTORIST $
J ti $
fB PHYSICAL DAMAGE DEDUCTIBLE ~ ALL VEHICLES U SCHEDULED VEHICLES ACTUAL CASH VALUE
~ t COLLISION: STATED AMOUNT $
;; OTHER THAN COL: OTHER
i!'.
FGE UABIUTY AUTO ONLY - EA ACCIDENT $
_ ANY AUTO OTHER THAN AUTO ONLY:
, ;,-
;;~ EACH ACCIDENT $
2 AGGREGATE $
EXCESS LIABILITY EACH OCCURRENCE $
H UMBRELLA FORM AGGREGATE $
i; OTHER THAN UMBRELLA FORI\:! RErRO DATE FOR CLAIMS MADE: SELF-INSURED RETENTION $
WC STATUTORY LIMITS
J WORKER'S COMPENSATION E.L EACH ACCIDENT $
AND
EMPLOYER'S UABILrrY E.L. DISEASE - EA EMPLOYEE $
E.L. DISEASE - POLICY LIMIT $
? TI~~<&'ft-TONSI This binder is issued pending receipt of the insurance policy and is FEES $
Subject to the provisions and exclusions enumerated in the policy.
, 'ITHER TAXES $
lJOVERAGES ESTIMATED TOTAL PREMIUM $
NAME & ADDRESS
MORTGAGEE
LOSS PAYEE
LOAN #
ADDITIONAL INSURED
):
~1,.CORD 75 (2004/09)
lJJ
ACORD CORPORATION 1993.2004
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INSURANCE BINDER NUMBER 12819
NAMED INSURED AND
MAILING ADDRESS:
NAME AND ADDRESS OF DESIGNATED
CONTRACTOR:
NAME AND ADDRESS OF AUTHORITY
FOR WHOM THE WORK WILL BE
PERFORMED:
CONTRACT COST:
DESCRIPTION OF PROJECT:
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f":, POLlCY FORMS:
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U-GU-692-A CW
U-GU-D-310-A
U-GU-319-S
U-GU-618-A CE
U-GU-619-A CW
IL 00 21
IL 01 58
IL 00 03
UGL 1179ACW
UGL 1181ACW
U-GL-495-A CW
U-GL-D-275-B CW
U-GL-1113-A CW
CG 00 09
CG 29 25
PROVISIONS:
CITY OF JEFFERSONVILLE, INDIANA,
ENVIRONMENTAL MANAGEMENT CORPORATION &
STRAND ASSOCIATES, INC.
CITY COUNTY BUILDING 4TH FLOOR
501 E. COURT AVENUE
JEFFERSONVILLE, IN 47130
MITCHELL & STARK CONSTRUCTlON CO., INC.
P.O. BOX219
MEDORA, IN 47260
CITY OF JEFFERSONVILLE, IN
CITY COUNTY BUILDING 4TH FLOOR
501 E. COURT AVENUE
JEFFERSONVILLE,IN 47130
$365,146
RECONSTRUCTION OF RIVERPORT NO.2 PUMP
STATION, INCLUDING NEW WET VALVE, VALVE
VAULT AND NEW PUMPS. PROJECT INCLUDES
CONSTRUCTION OF A NEW CONCRETE BLOCK
PUMP HOUSE APPROXIMATELY 200 SQ. FEET IN
AREA.
DISCLOSURE OF PREMIUM (RELATING TO TRIA)
COMMON POLICY DECLARATIONS
IN WITNESS CLAUSE
SCHEDULE OF LOCATIONS
SCHEDULE OF FORMS AND ENDORSEMENTS
NUCLEAR ENERGY LIABILITY EXCLUSION ENDT
INDIANA CHANGES
CALCULATION OF PREMIUM
ASBESTOS EXCLUSION ENDORSEMENT
FUNGI OR BACTERIA EXCLUSION ENDT
OCP LIABILITY LOCATION SCHEDULE
OWNERS CONTRACTORS PROTECTIVE L1AB DEC
COMM GENERAL LIABILITY COVERAGE SCHEDULE
ocr COVERAGE FORM-DESIGNATED CONTRACTOR
CHANGES-CANC. & NON-RENEWAL-OCP
THIRTY (30) DAY WRITTEN NOTICE OF
CANCELLATION SHALL BE PROVIDED TO THE
INSURED, THE CONTRACTOR AND STRAND
ASSOCIATES. INC.
....~~
:'rITHIS BINDER 1$ A TEMPORARY INSURANCE CONTRACT, SUBJECT TO THE CONDITIONS SHOWN ON THE REVERSE Sloe OFTHIS FORM.
: AGENCY' ' COMPANY BINDER# 12817
Fireman's Fund
INSURANCE BINDER .
OP ID C2
DATE (MMlDD/YYYY'}
08/03/2007
317-844-9910
AM
PM
08/15/0B
Lifobias Insurance Group, Inc.
19247 N. Meridian St. Ste. 300
,.;Lndianapolis IN 46260
I rUck J. Ruti liano
l lAIC, No. Ext}: 317 - 844-77 59
CODE: 1.3097366
f .;;USTOMER 10: MITCH- 0
i iNSURED
11; Mitchell &: Stark Construction
Co., Inc. (See Attachment)
f , P. O. Box 219
, . Medora IN 47260
DATE
EFFECTIVE
DATE.
TIME
X 12:01 AM
NOON
THIS BINDER IS ISSUED TO EXTEND COVERAGE IN THE ABOVE NAMED COMPANY
PER EXPIRING POLlCY' #; MZI97910712
DESCRIPTION OF OPERATIONSNEHICLESIPROPERTY (Including Location)
Near Intersection of Utica Pike and Port
Road, Jeffersonville, IN - Contract 1-2007
- Riverport No. 2 Pump station &: Force
MainUpgrades
;
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COVERAGES
LIMITS
,-
f .~ TYPE OF INSURANCE COVERAGElFORMS DEDUCTIBLE COINS % AMOUNT
\ .'ROPERTY CAUSES OF LOSS Builder's Risk 5,000 90 365,146
~~ BASIC o BROAD [!] SPEC Property In Transit/Temp Loe 5,000 90 100,000
< .X Builder ~ s aisk Coverage
;
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~~ERAL LIABILITY' EACH OCCURRENCE $
, ,._ 5MERClAL GENERAL LIABILITY ~~~8~~EMISES $
l' CLAIMS MADE D OCCUR MED EXP (Anyone person) $
.1-
it- PERSONAL & ADV INJURY $
GENERAL AGGREGATE $
fr ':' RETRO DATE FOR CLAIMS MADE: PRODUCTS - COMP/OP AGG $
i "UTOMOBILE LIABILITY COMBINED SINGLE LIMIT $
, ;-
~L ANY AUTO BODILY INJURY' (Per person) $
\ ALL OWNED AUTOS BODILY INJURY (Per accident} $
f-
l SCHEDULED AUTOS PROPERTY DAMAGE $
tt- HIRED AUTOS MEOICAL PAYMENTS $
I--
'1= NON-.OWNED AUTOS PERSONAL INJURY PROT $
UNINSURED MOTORIST $
S
AUTO PHYSICAL DAMAGE DEDUCTIBLE ==r AU VEHICLES U SCHEDULED VEHICLES ACTUAL CASH VALUE
lR COUISION: STATED AMOUNT $
I ~ OTHER THAN COL: OTHER
L1
GARAGE LIABILITY AUTO ONLY - EA ACCIDENT $
f-
,~= ANY AUTO OTHER THAN AUTO ONLY.
EACH ACCIDENT S
AGGREGATE $
EXCESS LIABILITY EACH OCCURRENCE $
R UMBRELLA FORM AGGREGATE $
OTHER THAN UMBRELLA FORM RETRO DATE FOR CLAIMS MADE: SELF-INSURED RETENTION $
WC STATUTORYLlMrTS
I WORKER'S COMPENSATION E.L. EACH ACCIDENT $
AND
EMPLOYER'S LIABILITY EL DISEASE - EA EMPLOYEE $
E.L DISEASE - POLICY LIMIT $
~PECIAL Named Insured(s), Mitchell. & Stark Construction Co. . Inc. - SEE ATTACHED FEES $
" );ONDITIONSI BINDER ADDENDUM - THIS BINDER IS ISSOED PENDING RECEIPT OF THE POLICY
.; hTHER AND IS SUBJECT TO THE PROVISIONS AND EXCLUSIONS ENUMERATED IN THE POLICY. TAXES $
1 !:OVERAGES I
~~." ESTIMATED TOTAL PREMIUM $
NAME & ADDRESS
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MORTGAGEE
LOSS PAYEE
LOAN #
ADDITIONAL INSURED
l~
~ hCORD 75 (2004/09)
U
NOTE: IMPORTANT SlATE INFOR ATI
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NAMED INSURED:
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PROJECT OWNER:
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INSURANCE BINDER #12817
MITCHELL & STA~K CONSTRUCTION CO.. INC.
MitpheU & Stark Construction Co., Inc.
Their Subcontractors and Sub-Subcontractors of Any
Tier, City of Jeffersonville, IN, Environmental
Management Corporation and Strand Associates, Inc.,
A.T.I.M.A.
P.O. Box 219
Medora, IN 47260
City of Jeffersonville, Indiana
City County Building 4th Floor
501 E. Court Avenue
Jeffersonville, IN 47130
Near Intersection of Utica Pike and Port Road
Jeffersonville, IN 47130
DESCRI PTION OF PROJECT:
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LIMITS OF LIABILITY:
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4 DEDUCTIBLE:
Reconstruction of Riverport NO.2 pump station,
including new wet valve, valve vault and new pumps.
Project includes construction of a new concrete block
pump house approximately 200 Sq. Feet in area.
$365,146 Completed Value Builders Risk
$100,000 Property in Transit
$100,000 Property at a Temporary Storage Location
$ 5,000 Deductible
MAJOR POLICY AMENDMENTS:
PERMISSION GRANTED FOR OCCUPANCY BY
OWNER, INCLUDES COVERAGE FOR TESTING,
FUNGI LIMITATION ENDORSEMENT,
DETRIMENTAL CODE EXCLUSION, EXCLUSION
OF ACTS OF BIOLOGICAL OR CHEMICAL
TERRORISM
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, TICE REGARDING TERRORISM COVERAGE - 386357 01 03
,~:!rt~.;.;'~
IM~g~t ANT
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\~~, ~@r
y au ar~\h,ereby/. ;,. ified that undE;lrhhe Terrorism Risk Insurance Act of 2002 ("The Act"), you have a right
to purch~~eHnsufance cove'g"ei;foF;'lgsses arising out of acts of terrorism, as defined in Section 102(1} of
The Act: The term "acto. .l8-rlsm""means any act that is certified by the Secretary of the Treasury, in
concurrence~with tb.~I:$.:~b ary of St~l~, and .the Attorney General of the United States - to be an act of
terrorism; to 8>~'i~r.~!,9'iefit aR~ or an acJ~!g:at is dangerous to human life, property; or infrastructure; to have
resulted in dan'i'age wittii!h, the ",United States, or outside the United States in the case of an air
carrier or vesse(\~r the premi~~€r~ft~~;United:~States mission; and to have been committed by an individual
or individuals acting on behal('o:rany for~Jgp person or foreign interest, as part of an effort to coerce
the civilian population of the United ~tat{4~pr~Jo influence the policy or affect the conduct of the United
States Government by coercion.,. ,,~r; .' ;f.r' '(l;,::.
~. ~~
You should know that coVe(, ~d by the pbljcy offered in this quote for losses caused by acts of
terrorism, as defined in T,.. ct, is partially reimbl!r~ed by the United States under a formula established
by The Act. Under this forln.!:I1a, the Unit~.c:l;"J5tate,~I'pays 90% of covered terrorism losses exceeding the
statutorily established deductible paid py"ffie insurance company providing the coverage. The premium
charged for this coverage is ptpvided 6'elow and does not include any charges for the portion of the loss
covered by the Federal governm~!.~f!cjer The..
'''t::::i:-~:.:;.~~~f;.:',,''''. ..
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This quotation includes an offer of covera~t~i_ osses due t2/ti:lrrorist acts, as defined by The Act, and, if
accepted, will be subject to the Iimit(s)~::.t~rms and conditions~:of any policy subsequently issued. The
quoted premium for this terrorism cover~@e is $31 'ifh
"":;'",-,,"
..;.:,>~;
In order to accept or reject this offer of t~rrorism coverage for 'the premiums stated above please do one
of the fOflOWing:':;;:~\t:~~'1;';",'" ."C ~li.~~,
To Reject this offer, do ALL of the following: 0 .......
(1) Communicate your decision to your agent or'RToke ,. 'cptesenting
The Fireman's Fund Insurance Companies; an(i' .'
(2) Mark the "Reject" option below, sign and date bE;i!ow, and ",,~,,':".',;::~j;/
return the originally signed document to your agEl'ht or brokerrlf:pfes~ntjng Fireman's
Fund Insurance Companies, . '('t~H$~~:):;);;;:;f,;"'A~lli~!~~!?
To Accept this offer, do ALL of the following: ." ,i:~,;fjt~F
(1) Communicate your decision to your agent or broker repre$ifi1flJ)g".,<"",
The Fireman's Fund Insurance Companie's; and&~''''''''''''
(2) Pay the premium by the due date shown on your premium billing.
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Please note that any coverage mandated by applicable Standard FirtfPolicy la\N3;iJQ"" orkers '\:\
Compensation laws in your state will not be affected by your rejection D@lowc J;!~t.rbli~;m coverage\
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If you have any questions about this or any other insurance matter, please:gontact your~~~e~Q1 or efBRer
representing the Fireman's Fund Insurance Companies. ",;~, Ait?~""
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386357 01 03 - Page 1 of 2
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TERR~,RISM C ' AGE ELE1;'ON:
o J RE'Jb:~I,qP'Y . RAGE F'4Q,S,SES DUE TO TERRORIST ACTS, AS DEFINED IN THE ACT.
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Applicant:
Signature:
Title:
::~ffince Company 1 '~~~~~Q~D I:$:~~CE CO.
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Please return to your agent or\broker rei'presenting the Fireman's Fund Insurance Companies.
Insured
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MITCHELL & STARK CON9t~> CTION CO
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Producer TOBIAS INSURANCE GRQ.UP, INC.
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Policy
Number
MZI9791 0712
Effective
Date
08/15/2007
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386357 01 03 - Page 2 of 2