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HomeMy WebLinkAbout2024 COISHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. INSURER(S) AFFORDING COVERAGE INSURER F : INSURER E : INSURER D : INSURER C : INSURER B : INSURER A : NAIC # NAME:CONTACT (A/C, No):FAX E-MAILADDRESS: PRODUCER (A/C, No, Ext):PHONE INSURED REVISION NUMBER:CERTIFICATE NUMBER:COVERAGES 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). 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. OTHER: (Per accident) (Ea accident) $ $ N / A SUBR WVD ADDL INSD 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. $ $ $ $PROPERTY DAMAGE BODILY INJURY (Per accident) BODILY INJURY (Per person) COMBINED SINGLE LIMIT AUTOS ONLY AUTOSAUTOS ONLY NON-OWNED SCHEDULEDOWNED ANY AUTO AUTOMOBILE LIABILITY Y / N WORKERS COMPENSATION AND EMPLOYERS' LIABILITY OFFICER/MEMBER EXCLUDED? (Mandatory in NH) DESCRIPTION OF OPERATIONS below If yes, describe under ANY PROPRIETOR/PARTNER/EXECUTIVE $ $ $ E.L. DISEASE - POLICY LIMIT E.L. DISEASE - EA EMPLOYEE E.L. EACH ACCIDENT EROTH-STATUTEPER LIMITS(MM/DD/YYYY)POLICY EXP(MM/DD/YYYY)POLICY EFFPOLICY NUMBERTYPE OF INSURANCELTRINSR DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) EXCESS LIAB UMBRELLA LIAB $EACH OCCURRENCE $AGGREGATE $ OCCUR CLAIMS-MADE DED RETENTION $ $PRODUCTS - COMP/OP AGG $GENERAL AGGREGATE $PERSONAL & ADV INJURY $MED EXP (Any one person) $EACH OCCURRENCE DAMAGE TO RENTED $PREMISES (Ea occurrence) COMMERCIAL GENERAL LIABILITY CLAIMS-MADE OCCUR GEN'L AGGREGATE LIMIT APPLIES PER: POLICY PRO-JECT LOC CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DD/YYYY) CANCELLATION AUTHORIZED REPRESENTATIVE ACORD 25 (2016/03) © 1988-2015 ACORD CORPORATION. All rights reserved. CERTIFICATE HOLDER The ACORD name and logo are registered marks of ACORD HIRED AUTOS ONLY 2/29/2024 Greyling Insurance Brokerage 3780 Mansell Road, Suite370 Alpharetta, GA 30022 National Union Fire Ins Co Pittsburgh PA 19445 Allied World Assurance Company (U.S.)19489 Argonaut Insurance Company 19801 New Hampshire Insurance Company 23841 Lloyds 085202 35378Evanston Insurance Company A 2,000,000GL 6360582 8/1/2023 8/1/2024 500,000 3 25,000 3 2,000,000 4,000,000 4,000,00033 A CA 5774680 8/1/2023 8/1/2024 2,000,000 3 B 0313-5205 8/1/2023 8/1/202433 3 3 10,000 C WC 013265763 (AOS)8/1/2023 8/1/2024 3 D WC 013265764 (CA)8/1/2023 8/1/2024 1,000,000N 1,000,000 1,000,000 E Professional Liability B0146LDUSA2305147 8/1/2023 8/1/2024 Per Claim $5,000,000 Aggregate $5,000,000 F Pollution Liability CPLMOL112871 8/1/2023 8/1/2024 Per Occurrence $5,000,000 Matias Ormaza Jerry Noyola jerry.noyola@greyling.com Aggregate $5,000,000 Carter Associates, Inc. 1708 21st Street Vero Beach FL 32950 78879502 RFQ #21-01 – Continuing Engineering Services Contract Professional Liability is written on a claims-made basis City of Sebastian - City Hall 1225 Main Street Sebastrian FL 32958 10,000,000 10,000,000 3 78879502 | 23/24 Master Certificate | Stacee Martinka | 2/29/2024 2:05:52 PM (CST) | Page 1 of 2 ACORD 101 (2008/01) The ACORD name and logo are registered marks of ACORD © 2008 ACORD CORPORATION. All rights reserved. THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, FORM NUMBER:FORM TITLE: ADDITIONAL REMARKS ADDITIONAL REMARKS SCHEDULE Page of AGENCY CUSTOMER ID: LOC #: AGENCY CARRIER NAIC CODE POLICY NUMBER NAMED INSURED EFFECTIVE DATE: **Additional Named Insureds**: Berg-Oliver Associates; 14701 St. Mary's Lane, Suite 400; Houston, TX 77079 Horizon Environmental Services; 1507 South IH 35; Austin, TX 78741 LJA Infrastructure, Inc.; 3600 W Sam Houston Pkwy S, Suite 150; Houston, TX 77042 LJA Rail, LLC; 3600 W Sam Houston Pkwy S, Suite 150; Houston, TX 77042 LJA Surveying, Inc.; 3600 W Sam Houston Pkwy S, Suite 175; Houston, TX 77042 LJA Builds, Inc.; 3600 W Sam Houston Pkwy S, Suite 150; Houston, TX 77042 LJA Environmental Services, LLC; 14701 St. Mary's Lane, Suite 400; Houston, TX 77042 LJA Program Management, LLC (fka Ramos Consulting, LLC); 6720 Vaught Ranch Road, Suite 140, Austin, TX 78730 LJA Energy, Inc 3600 W Sam Houston Pkwy S, Suite 600; Houston, TX 77042 LJA Telecom, Inc. (fka GXT, Inc. or GXT, Ltd.) 2700 La Frontera Boulevard Suite 150 Round Rock, TX 78681 Paragon Consulting Group, Inc. 350 Airport Rd, Griffin, GA 30224 Alliance Engineering & Planning LLC; Alliance Surveying LLC; DBA Alliance Engineering, Planning, Landscape Architecture; 299 S Main Street, Suite A, Alpharetta, GA 30009 Carter Associates, Inc. 1708 21st Street Vero Beach, FL 32950 LJA Telecom Construction, Inc., LJA Engineering, Inc., 3600 W Sam Houston Pkwy. S, Suite 600, Houston, TX 77042 Donald W. McIntosh Associates, Inc., 2200 Park Avenue North, Winter Park, Florida 32789 Afendras Archaeology, 746 E. Center Road, Goldsby, OK 73093 General Liability Maximum Annual Aggregate limit $10,000,000 All policies listed (except for Work Comp and Professional Liability) include an automatic Additional Insured that provides Additional Insured status to the Certificate Holder only when there is a written contract that requires such status, and only regarding work performed on behalf of the named insured per policy forms CG2010 12/19 (includes ongoing operations) & CG2037 12/19 (GL); CA 2048 12/13 (Auto). Coverage provided on the General and Auto Liability is primary and non-contributory if required by a written contract executed prior to a loss. All policies listed provide a Blanket Waiver of Subrogation when required by written contract executed prior to a loss per policy forms CG 2404 12/19 (GL); CA 20 48 (10/13)(Auto); and WC 00 03 13 (4/84) (WC). The Umbrella Liability policy follows form to the underlying General, Automobile and Employers Liability policies. All policies listed include an endorsement providing that 30 days notice of cancellation for reasons other than nonpayment of premium and 10 days notice of cancellation for non- payment of premium will be given to the Certificate Holder by the Insurance Carrier, if required by written contract. Greyling Insurance Brokerage Carter Associates, Inc. 1708 21st Street Vero Beach FL 32950 25 Certificate of Liability (03/16) ATTACHMENT HOLDER: ADDRESS: City of Sebastian - City Hall 1225 Main Street Sebastrian FL 32958 78879502 | 23/24 Master Certificate | Stacee Martinka | 2/29/2024 2:05:52 PM (CST) | Page 2 of 2