Instructions to Professional: A standard Evidence of Insurance will not satisfy these requirements. Please forward this Attachment 2 and the Sample Certificates of Insurance to your Insurance Provider (Broker, Agent) for handling. Questions? Send an email to: the Manson Project Manager or ContractsandInsurance@MansonConstruction.com and include the Manson Construction Co. Job Number and Project name in the email Subject line. PROFESSIONAL SERVICE AGREEMENT ATTACHMENT 2 - MANSON CONSTRUCTION CO. INSURANCE REQUIREMENTS Manson Construction Co. Job No.: 75-15-102 Project Name and Location: Sandy Hook to Barnegat Inlet Erosion Control Project, Elberon to Loch Arbour Reach, Contract 1 Loch Arbour to Deal, NJ; USACE Contract W912DS-15-C-0006 GENERAL PROVISIONS. 1. This Attachment supplements the general terms and conditions of this Agreement. Capitalized terms have the meanings ascribed to them in the Agreement. 2. Manson does not represent that the required minimum insurance is adequate to protect Professional from claims arising out of its operations or this Agreement. 3. Failure to continuously satisfy the insurance requirements herein is a material breach of this Agreement. 4. Insurance deductibles related to Claims that are intended to be covered by insurance policies required herein, shall be sole responsibility of Professional, as well as Claims exceeding required policy limits. 5. Required insurance shall be in full force and effect at all times operations are performed by Professional, its sub-tier subcontractors, vendors, or anyone directly or indirectly employed by any of them or for whose acts Professional may be liable, and for such longer period as the Agreement and Prime Contract may require; warranty work included. 6. Certificates of Insurance and Endorsements are DUE BEFORE STARTING WORK, INCLUDING WARRANTY WORK. Prior to commencing Work and as a condition precedent to payment, Professional shall provide to Contractor, evidence of insurance as described in this Attachment but in no event may insurance coverage be less than required in the Agreement and Prime Contract. If work is subcontracted, Professional shall also provide proof that lower-tier subcontractors insurance meets the requirements outlined in this Attachment. 7. It is the sole responsibility of Professional to comply with this Attachment. Acceptance by Contractor of certificates and/or endorsements that do not in fact meet the requirements of this Attachment shall not relieve Professional of the insurance procurement requirements in this Attachment, nor shall it be deemed a waiver by Contractor of its right to enforce the Agreement if it is later determined that the required insurance was not properly procured. 8. If Professional fails or refuses to obtain any coverage required herein (whether due to its actions or those of its insurance provider): 1) it shall be solely liable for all uncovered claims to which that coverage would apply; and 2) Contractor may, but is not required to, maintain such coverage and charge the expense to Professional; and 3) Contractor reserves all remedies under the Agreement. NOTE: See PROOF OF INSURANCE REQUIREMENTS beginning on page 5 of this Attachment, including Project Specific language that must be included on the ACORD form(s). Items highlighted in the table below are required only as described (depending on the Scope of Work).
Insurance Requirements Professional Service Agreement Attachment 2 Page 2 Required Coverage Description Minimum Limits Endorsements Required Commercial General Liability 1. Commercial General Liability Insurance on ISO Form CG 00 01 04 13 or equivalent. USD 1,000,000 per occurrence; USD 50,000 damage to rented premises; USD 5,000 medical expense USD 1,000,000 personal and advertising injury; USD 2,000,000 products completed operations aggregate; USD 2,000,000 general aggregate; 1. Additional Insured, ISO CG 20 10 (11/85) edition, or equivalent. 2. Primary and Non-Contributory, ISO Form CG 20 01 3. Waiver of Subrogation (Waiver of Transfer of Rights) 4. Watercraft Exclusion deleted if Scope of Work involves watercraft. Business Auto 1. Business Auto policy. ISO Form CA 00 01 03 06 2. Covering all owned, non-owned, hired and/or rented licensed motor vehicles for bodily injury and/or property damage. 3. Pollution coverage if hauling contaminated or hazardous waste, including MCS 90 endorsement. Excess Liability 1. Excess liability insurance following form and in excess of underlying policies. 2. Coverage shall be excess over; (a) commercial general liability, employer s liability, automobile liability; and (b) as applicable, maritime employer s liability, and protection and indemnity insurance with limits of not less than USD 4,000,000. 3. Limits for such coverages of not less than the highest maximum levels of a combination of primary and excess insurance maintained by Professional and any of its parent, subsidiary or affiliated entities but in no event in a combination of primary and excess coverage less than 5,000,000. 1 USD 1,000,000 per accident 1. Additional Insured 2. Primary and Non-Contributory 3. Waiver of Subrogation (Waiver of Transfer of Rights) 4. MCS 90 if Scope of Work includes hauling contaminated or hazardous waste. USD 4,000,000 per occurrence If policies follow primary form, no endorsements required but COI must identify policies covered by excess insurance. 1 Required limits of 5M may be met with any combination of underlying and excess coverage. PSA ATT 2 - INS REQ - MCC 75-15-102.docx Revised 01-13-15
Insurance Requirements Professional Service Agreement Attachment 2 Page 3 Required Coverage Description Minimum Limits Endorsements Required Workers Compensation / Statutory limits for workers Employers Liability compensation USL&H may be required see ADDITIONAL REQUIREMENTS FOR APPLICABLE OPERATIONS section below and Footnote 3. Contractor s Pollution & Environmental Liability 1. Workers compensation in full compliance with all applicable State and Federal laws and regulations (statutory limits). 2. Include a minimum Employer s Liability policy limit of USD 1,000,000.00 each person, each accident and aggregate. 3. Include borrowed servant or alternate employer endorsement naming Manson Construction Co., and all its associated and affiliated companies ( Manson ), as the alternate employer and stating that an action brought against Manson under the theory of borrowed servant or alternate employer or any similar theory will be treated as a claim against Professional. 1. Coverage for claims investigation, defense and/or settlement costs and expenses, damages, clean-up and restoration including natural resource damages and loss of use of tangible property that has not been physically damaged, third-party bodily injury, and remediation to include any work over water or limits required by applicable Federal and/or State statutory limits, whichever is greater. 2. For operations on non-owned disposal site, insurance shall cover onsite, offsite, in transit, handling, storing or generating hazardous materials or any substance otherwise regulated under any environmental law or regulation. 3. No exclusion for contaminated or hazardous waste if Scope of Work includes asbestos or lead abatement. Contractor s Equipment 1. Coverage in an amount equal to the full market value of the interest insured. Watercraft exclusion deleted if applicable. 2. Professional and its sub-tier contractors and consultants shall be responsible for liability and physical damage coverage of their owned and leased equipment. USD 1,000,000 employer s liability per accident USD 1,000,000 per claim Full market value of Professional s interest in the equipment 1. Borrowed Servant or Alternate Employer 2. Waiver of Subrogation (Waiver of Transfer of Rights) 1. Additional Insured 2. Primary and Non-Contributory 3. Waiver of Subrogation (Waiver of Transfer of Rights) Waiver of Subrogation (Waiver of Transfer of Rights) PSA ATT 2 - INS REQ - MCC 75-15-102.docx Revised 01-13-15
Insurance Requirements Professional Service Agreement Attachment 2 Page 4 ADDITIONAL REQUIREMENTS FOR APPLICABLE OPERATIONS [See also highlighted and underlined text above] Required Coverage Description Minimum Limits Endorsements Required See Footnote 2 USL&H 2 1. Include United States Longshore and Harbor Workers Compensation Act coverage for employees. Statutory limits Maritime Employer s Liability below 2. Include maritime employers liability endorsement, including transportation, wages, maintenance and cure unless such See Footnote 3 below See Footnote 3 below Wharfinger s Legal Liability, Ship Repairer s Legal Liability 3 Marine Hull & Machinery coverage is provide by the required P&I policy. 1. Unless included elsewhere, coverage shall include Wharfinger s Legal Liability applicable to third-party vessels in Professional s care, custody or control. Such coverage to include voluntary wreck removal. 2. Unless included elsewhere, coverage shall include Ship Repairer s Legal Liability applicable to the third-party vessels in the Professional s care, custody or control for the purposes of repair. Such coverage to include voluntary wreck removal. Primary hull insurance subject to not less than the terms and conditions of the Pacific Coast Tug and Barge Form 1979, or American Institute Hull Clause 9/29/09, or equivalent, in the amount sufficient to cover each vessel owned or under Professional s care custody and control (e.g. Bare Boat Chartered to Professional) in connection with operations under this Agreement, to not less than the actual value of each vessel, including collision and tower s liability, War Risk, and Strikes, Riots & Civil Commotion (SR&CC). USD 5,000,000 per occurrence Not less than actual value of applicable vessels. Waiver of Subrogation (Waiver of Transfer of Rights) 2 NOTICE: Employees engaged in longshore operations and harborworkers, including ship repairmen, shipbuilders, ship breakers, and marine construction employees, and persons who work in part upon navigable waters of the US including any adjoining pier, wharf, dry dock, terminal, building way, marine railway, or other adjoining area customarily used by an employer loading, unloading, building, repairing or dismantling a vessel are subject to the United States Longshore and Harbor Workers Compensation Act. By law, benefits are payable to the employee and/or the employee s dependents for disability or death. State workers compensation will not cover or provide coverage for anyone entitled to benefits under USL&H. Coverage is required by law where the type of work or job and the location of the injury establish eligibility. Failure of an employer to provide proper coverage may result in fines of 10,000 per claim, imprisonment of up to one (1) year, or both. A good website that may help identify USL&H exposure is http://www.longshorefactor.com Coverage may be available through the Washington State USL&H Risk Pool. Additional information at http://warp-uslh.org 3 Required if Professional s Scope of Work includes the use of any vessels owned, leased, operated, or in the custody care and control of Professional, including any vessel Bareboat Chartered to Professional. PSA ATT 2 - INS REQ - MCC 75-15-102.docx Revised 01-13-15
Insurance Requirements Professional Service Agreement Attachment 2 Page 5 ADDITIONAL REQUIREMENTS FOR APPLICABLE OPERATIONS [See also highlighted and underlined text above] Required Coverage Description Minimum Limits Endorsements Required See Footnote 3 on page 4. Marine Protection & Indemnity USD 5,000,000 per occurrence See Footnote 3 on page 4. If Professional s Work includes professional or design services. Water Quality Insurance Primary protection and indemnity insurance subject to the terms and conditions of not less than the P&I SP-23 (Revised 1/56) form of policy or its equivalent, and including contractual liability, collision/tower s liability, and voluntary wreck removal, with limit of USD 5,000,000 applicable to any one accident or occurrence. Unless provided by the Workers Compensation coverage required herein, coverage shall further include crew coverage for crew (Jones Act) including transportation, wages, maintenance and cure. Statutory marine pollution insurance providing coverage for OPA, CERCLA and other regulations for all owned, chartered and operated vessels. Professional Liability 1. Coverage for professional errors and omissions. 2. If design related professional services include pollution conditions, coverage shall include pollution liability coverage. 3. Extended reporting period of three (3) years from conclusion of operations or Agreement or Prime Contract requirement, whichever is longest. PROOF OF INSURANCE REQUIREMENTS: Statutory USD 1,000,000 per occurrence 1. Additional Insured. 2. Waiver of Subrogation (Waiver of Transfer of Rights) 1. Additional Insured. 2. Waiver of Subrogation (Waiver of Transfer of Rights Waiver of Subrogation (Waiver of Transfer of Rights) 1. Current ACORD form required. Evidence of insurance to be provided on the currently approved ACORD 25 and/or 101 Certificate of Insurance form. Previously issued ACORD forms may be rejected. 2. Endorsements Required. Attach ALL policy endorsements listed as required on ACORD form sample and in description above. 3. Additional Insureds. Manson Construction Co., and all its associated and affiliated companies, employees and agents, the Project Owner, and other parties required by written contract (see item 8 on page 6 of this Attachment), to be so named (collectively the AIs) shall be named as Additional Insureds on the policies listed above (excepting only Workers Compensation, Hull & Machinery, Contractor s Equipment, and Professional Liability). Additional Insured endorsements shall not: a) be limited to on-going Operations, b) exclude Contractual Liability, c) restrict coverage to the sole liability of the Professional, or d) contain any other exclusion contrary to the Agreement or Prime Contract. 4. Primary and Non-Contributory. Insurance afforded by Professional policies shall be primary and non-contributory to any other valid and collectible insurance the AIs may have with respect to loss under the policy. Other insurance applicable to any such loss shall be excess over the AIs polices, and AIs liability amount shall not be reduced by the existence of any other insurance. PSA ATT 2 - INS REQ - MCC 75-15-102.docx Revised 01-13-15
Insurance Requirements Professional Service Agreement Attachment 2 Page 6 5. Waiver of Subrogation. All insurance policies required above shall contain the provision that the insurance companies waive the right of subrogation against Manson Construction Co., and all its associated and affiliated companies, employees and agents, the Project Owner, and other parties required by written contract to be so named (collectively the AIs). 6. Insurers. Insurance policies must be provided from insurers with an A.M. Best financial rating of A-VII (7) or higher. Notification within 30 days of rating under minimum requirements. 7. Notice of Cancellation or Material Change in Coverage. Policies shall not be cancelled or coverage reduced by endorsement until a thirty (30) day written notice of cancellation has been served upon Contractor and receipt of Notification of Cancellation or Non-Renewal of policy. Provide additional information regarding replacement insurance provider. 8. Project Specific Requirements. ACORD 25 Include the following in the DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (Attach ACORD 101, Additional Remarks Schedule if more space is required) BO: Manson Construction Co. Job No.: 75-15-102 Project Name and Location: Sandy Hook to Barnegat Inlet Erosion Control Project, Elberon to Loch Arbour Reach, Contract 1 Loch Arbour to Deal, NJ; USACE Contract W912DS-15-C-0006 ACORD 101 Additional Remarks Schedule Include the following: Manson Construction Co. and all its associated and affiliated companies are named as Primary and Non-Contributory Additional Insureds with Waiver of Subrogation. Additional Insured, Primary and Non-Contributory, and Waiver of Subrogation Endorsements ARE ATTACHED. PSA ATT 2 - INS REQ - MCC 75-15-102.docx Revised 01-13-15
ACORD@ ~ f - f f CLAIMS-MADE 0 D npolicyn JECT n PRO- GEN'L AGGREGATE LIMIT APPLIES PER: AUTOMOBILE LIABILITY ANY AUTO ALL OWNED AUTOS SCHEDULED AUTOS HIRED AUTOS NON-OWNED AUTOS COMMERCIAL GENERAL LIABILITY DEDUCTIBLE H CERTIFICATE OF LIABILITY INSURANCE INSR ADDL SUBR LTR TYPE OF INSURANCE INSR WVD POLICY NUMBER GENERAL LIABILITY OCCUR y LOC RETENTION WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANY PROPRIETOR/PARTNER/EECUTIVE OFFICER/MEMBER ECLUDED? (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below *Professional Liability *Contractors Pollution *Contractors Equipment POLICY EFF (MM/DD/YYYY) POLICY EP (MM/DD/YYYY) ÕÕÕÕÕÕÕÕÕÕÕÂÂÂÂÂÂÂÂÂÂÂÂÂÂÂÂÂÂÂÂÂÂÂÂÂÂÂÂÂÂÂÂÂEffÂÏateÂÂÂÂÂÂÂÂExpÂÏate I TORY LIMITS I I ER Y / N ÒÑL&H CT E.L. EACH ACCIDENT 1,000,000 DN ÆI E.L. DISEASE - EA EMPLOYEE 1,000,000 E.L. DISEASE - POLICY LIMIT 1,000,000 Eff Date Exp Date 1,000,000 y Eff Date Exp Date 1,000,000 Market Value I DATE (MM/DD/YYYY) 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, ETEND 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 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 ÖÜurÂInsuranceÂPrÜvider ÑtreetÂÍddress City,ÂÑtateÂZipÂÂÂÂÂÂÂÂÂÂÂÂÂÂÂÂÂÂÂÂÂÂÂÂÂÂÂÂÂÂÂÂÂÂÂÂÂÂÂÂÂÂÂÂÂÂÂÂÂÂÂÂÂÂÂÂÂÂÂÂÂÂÂÂÂÂÂÂÂÂÂÂÂPhÜneÂ# INSURED ÖÜurÂCÜÛpanyÂNaÛe ÑtreetÂÍddress City,ÂÑtateÂZipÂÂÂÂÂÂÂÂÂÂÂÂÂÂÂÂÂÂÂÂÂÂÂÂÂÂÂÂÂÂÂÂÂÂÂÂÂÂÂÂÂÂÂÂÂÂÂÂÂÂÂÂÂÂÂÂÂÂÂÂÂÂÂÂÂÂÂÂÂÂÂÂPhÜneÂ# NAME: PHONE (A/C, No, Ext): E-MAIL ADDRESS: PRODUCER CUSTOMER ID #: INSURER A : INSURER B : INSURER C : INSURER D : INSURER E : INSURER F : COVERAGES CERTIFICATE NUMBER: 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, ECLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. Í Î Õ C Õ UMBRELLA LIAB Õ OCCUR ÕÕÕÕÕÕÕÕÕÕÕÂÂÂÂÂÂÂÂÂÂÂÂÂÂÂÂÂÂÂÂÂÂÂÂÂÂÂÂÂÂÂÂÂEffÂÏateÂÂÂÂÂÂÂÂExpÂÏate EACH OCCURRENCE 4,000,000 ECESS LIAB CLAIMS-MADE AGGREGATE 4,000,000 Ï A B C DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required) INSURER(S) AFFORDING COVERAGE InsuranceÂCÜÛpanyÂÍ InsuranceÂCÜÛpanyÂÎ InsuranceÂCÜÛpanyÂC InsuranceÂCÜÛpanyÂÏ Õ Õ ÕÕÕÕÕÕÕÕÕÕÕÂÂÂÂÂÂÂÂÂÂÂÂÂÂÂÂÂÂÂÂÂÂÂÂÂÂÂÂÂÂÂÂÂÂEffÂÏateÂÂÂÂÂÂÂExpÂÏate SAMPLE NON-MARITIME ÕÂÂÂÂÂÂÂÂÂÂÂÂÂÂÂÂÕÕÕÕÕÕÕÕÕÕÕÂÂÂÂÂÂÂÂÂÂÂÂÂÂÂÂÂÂÂÂÂÂÂÂÂÂÂÂÂÂÂÂÂÂEffÂÏateÂÂÂÂÂÂÂExpÂÏate LIMITS EACH OCCURRENCE 1,000,000 DAMAGE TO RENTED PREMISES (Ea occurrence) 50,000 È0,000 MED EP (Any one person) 5,000 Ë,000 PERSONAL & ADV INJURY 1,000,000 GENERAL AGGREGATE 2,000,000 PRODUCTS - COMP/OP AGG 2,000,000 COMBINED SINGLE LIMIT (Ea accident) 1,000,000 BODILY INJURY (Per person) BODILY INJURY (Per accident) PROPERTY DAMAGE (Per accident) Eff Date Exp Date Full Market Value FA I (A/C, No): MCC --; Project Name and contract number; Legal address location (See Insurance Requirements Attachment) WC STATU- OTH- 1/19/14 É,000,000 É,000,000 4,000,000 4,000,000 NAIC # *Required if applicable CERTIFICATE HOLDER MansÜnÂCÜnstructiÜnÂCÜÇ ÆÍddressÂÜfÂMansÜnÂÜfficeÂprÜvidingÂagreeÛent) 2 CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE ACORD 25 (2009/09) I 1988-2009 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD
AGENCY CUSTOMER ID: LOC #: ADDITIONAL REMARKS SCHEDULE Page 1 of 1 AGENCY NAMED INSURED POLICY NUMBER CARRIER ADDITIONAL REMARKS NAIC CODE EFFECTIVE DATE: THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, FORM NUMBER: 25 FORM TITLE: CERTIFICATE OF LIABILITY INSURANCE Manson Construction Co. and all its associated and affiliated companies, and the Project Owner, and other parties required by the Prime Contract to be named, [including e.g. City of such and such ] are named as Primary and Non-Contributory Additional Insureds with Waiver of Subrogation. (See Insurance Requirements Attached) Additional Insured, Primary and Non-Contributory, and Waiver of Subrogation Endorsements ARE ATTACHED. SAMPLE NON-MARITIME ACORD 101 (2008/01) 2008 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD
ACORD@ ~ f - CLAIMS-MADE 0 D npolicyn JECT n PRO- GEN'L AGGREGATE LIMIT APPLIES PER: AUTOMOBILE LIABILITY ANY AUTO ALL OWNED AUTOS SCHEDULED AUTOS HIRED AUTOS NON-OWNED AUTOS COMMERCIAL GENERAL LIABILITY H CERTIFICATE OF LIABILITY INSURANCE INSR ADDL SUBR LTR TYPE OF INSURANCE INSR WVD POLICY NUMBER GENERAL LIABILITY OCCUR *Protection & Indemnity f y 5,000,000 f *Wharfinger's Legal Liab/Ship Repairers 5,000,000 DEDUCTIBLE LOC RETENTION WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANY PROPRIETOR/PARTNER/EECUTIVE OFFICER/MEMBER ECLUDED? (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below *Marine Pollution/Water Quality *Hull & Machinery *Professional Liability POLICY EFF (MM/DD/YYYY) POLICY EP (MM/DD/YYYY) ÕÕÕÕÕÕÕÕÕÕÕÂÂÂÂÂÂÂÂÂÂÂÂÂÂÂÂÂÂÂÂÂÂÂÂÂÂÂÂÂÂÂÂÂEffÂÏateÂÂÂÂÂÂÂÂExpÂÏate I TORY LIMITS I I ER Y / N ÒÑL&H USL&H/MEL/JONES ACT CT E.L. EACH ACCIDENT 1,000,000 DN ÆI E.L. DISEASE - EA EMPLOYEE 1,000,000 E.L. DISEASE - POLICY LIMIT 1,000,000 Eff Date Exp Date Statutory Limits y Eff Date Exp Date Not Less Market Than Actual Value Value of Vessels I DATE (MM/DD/YYYY) 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, ETEND 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 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 ÖÜurÂInsuranceÂPrÜvider ÑtreetÂÍddress City,ÂÑtateÂZipÂÂÂÂÂÂÂÂÂÂÂÂÂÂÂÂÂÂÂÂÂÂÂÂÂÂÂÂÂÂÂÂÂÂÂÂÂÂÂÂÂÂÂÂÂÂÂÂÂÂÂÂÂÂÂÂÂÂÂÂÂÂÂÂÂÂÂÂÂÂÂÂÂPhÜneÂ# INSURED ÖÜurÂCÜÛpanyÂNaÛe ÑtreetÂÍddress City,ÂÑtateÂZipÂÂÂÂÂÂÂÂÂÂÂÂÂÂÂÂÂÂÂÂÂÂÂÂÂÂÂÂÂÂÂÂÂÂÂÂÂÂÂÂÂÂÂÂÂÂÂÂÂÂÂÂÂÂÂÂÂÂÂÂÂÂÂÂÂÂÂÂÂÂÂÂPhÜneÂ# NAME: PHONE (A/C, No, Ext): E-MAIL ADDRESS: PRODUCER CUSTOMER ID #: INSURER A : INSURER B : INSURER C : INSURER D : INSURER E : INSURER F : COVERAGES CERTIFICATE NUMBER: 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, ECLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. Í Î Õ C Õ UMBRELLA LIAB Õ OCCUR ÕÕÕÕÕÕÕÕÕÕÕÂÂÂÂÂÂÂÂÂÂÂÂÂÂÂÂÂÂÂÂÂÂÂÂÂÂÂÂÂÂÂÂÂEffÂÏateÂÂÂÂÂÂÂÂExpÂÏate EACH OCCURRENCE 4,000,000 ECESS LIAB CLAIMS-MADE AGGREGATE 4,000,000 Ï A B C DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required) INSURER(S) AFFORDING COVERAGE InsuranceÂCÜÛpanyÂÍ InsuranceÂCÜÛpanyÂÎ InsuranceÂCÜÛpanyÂC InsuranceÂCÜÛpanyÂÏ Õ Õ ÕÕÕÕÕÕÕÕÕÕÕÂÂÂÂÂÂÂÂÂÂÂÂÂÂÂÂÂÂÂÂÂÂÂÂÂÂÂÂÂÂÂÂÂÂEffÂÏateÂÂÂÂÂÂÂExpÂÏate SAMPLE - MARITIME ÕÂÂÂÂÂÂÂÂÂÂÂÂÂÂÂÂÕÕÕÕÕÕÕÕÕÕÕÂÂÂÂÂÂÂÂÂÂÂÂÂÂÂÂÂÂÂÂÂÂÂÂÂÂÂÂÂÂÂÂÂÂEffÂÏateÂÂÂÂÂÂÂExpÂÏate Eff Date Exp Date 1,000,000 LIMITS EACH OCCURRENCE 1,000,000 DAMAGE TO RENTED PREMISES (Ea occurrence) 50,000 È0,000 MED EP (Any one person) 5,000 Ë,000 PERSONAL & ADV INJURY 1,000,000 GENERAL AGGREGATE 2,000,000 PRODUCTS - COMP/OP AGG 2,000,000 COMBINED SINGLE LIMIT (Ea accident) 1,000,000 BODILY INJURY (Per person) BODILY INJURY (Per accident) PROPERTY DAMAGE (Per accident) FA I (A/C, No): MCC --; Project Name and contract number; Legal address location (See Insurance Requirements Attachment) WC STATU- OTH- 1/19/14 É,000,000 É,000,000 4,000,000 4,000,000 NAIC # *Required if applicable CERTIFICATE HOLDER MansÜnÂCÜnstructiÜnÂCÜÇ ÆÍddressÂÜfÂMansÜnÂÜfficeÂprÜvidingÂagreeÛent) 2 CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE ACORD 25 (2009/09) I 1988-2009 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD
AGENCY CUSTOMER ID: LOC #: ADDITIONAL REMARKS SCHEDULE Page 1 of 1 AGENCY NAMED INSURED POLICY NUMBER CARRIER ADDITIONAL REMARKS NAIC CODE EFFECTIVE DATE: THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, FORM NUMBER: 25 FORM TITLE: CERTIFICATE OF LIABILITY INSURANCE Manson Construction Co. and all its associated and affiliated companies, and the Project Owner, and other parties required by the Prime Contract to be named, [including e.g. City of such and such ] are named as Primary and Non-Contributory Additional Insureds with Waiver of Subrogation. (See Insurance Requirements Attached) Additional Insured, Primary and Non-Contributory, and Waiver of Subrogation Endorsements ARE ATTACHED. SAMPLE - MARITIME ACORD 101 (2008/01) 2008 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD