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Certificate of Insurance
ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? INSR ADDL SUBR LTR INSD WVD DATE (MM/DD/YYYY) 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 RENTED CLAIMS-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 AGG $JECT OTHER:$ 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 LIMIT $DESCRIPTION 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. The ACORD name and logo are registered marks of ACORDACORD 25 (2016/03) CERTIFICATE OF LIABILITY INSURANCE Lockton Companies 444 W. 47th Street, Suite 900 Kansas City MO 64112-1906 (816) 960-9000 OVERLAND CONTRACTING INC. 600 N GREENFIELD PKWY GARNER NC 27529 SETTER, SCOTT Lexington Insurance Company 19437 Lloyd's of London 38253 Zurich American Insurance Company 16535 AIG Specialty Insurance Company 26883 X X 2,000,000 100,000 10,000 2,000,000 4,000,000 4,000,000 X X X X 2,000,000 XXXXXXX XXXXXXX XXXXXXX XXXXXXX X X 10,000,000 10,000,000 XXXXXXX N X 1,000,000 1,000,000 1,000,000 PROFESSIONAL LIABILITY POLLUTION LIABILITY $10,000,000 PER CLAIM & ANN AGG FOR ALL PROJECTS $10,000,000 LIMIT A BAP 4641355 (AOS)11/1/2020 11/1/2021 A GLO 4641358 11/1/2020 11/1/2021 A GLO 1365630 11/1/2020 11/1/2021 C 026030198.11/1/2020 11/1/2021 D 2675375 11/1/2020 11/1/2021 B 62785285 11/1/2020 11/1/2021 A WC 4641353 (AOS)11/1/2020 11/1/2021 A WC 4641354 (ID, MA, WI)11/1/2020 11/1/2021 A WC 1365632 11/1/2020 11/1/2021 A WC 1365631 (NE)11/1/2020 11/1/2021 11/1/2021 1482179 Y Y Y Y Y Y Y 12/17/2020 N N 17198398 17198398 XXXXXXX CITY OF SALINA, KS 300 WEST ASH SALINA KS 67401 PROJECT NUMBER: 407340; PROJECT NAME: SALINA WWTP IMPROVEMENTS; PROJECT MANAGER: SETTER, SCOTT; GENERAL LIABILITY AND AUTO LIABILITY ARE PRIMARY AND NON-CONTRIBUTORY. CITY OF SALINA, KS IS INCLUDED AS AN ADDITIONAL INSURED ON THE GENERAL, AUTO, AND UMBRELLA POLICIES. WAIVER OF SUBROGATION IN FAVOR OF THE ADDITIONAL INSURED ON THE GENERAL, AUTO, UMBRELLA, AND WORKER’S COMPENSATION POLICIES. 30 DAY NOTICE OF CANCELLATION APPLIES, 10 DAYS NOTICE FOR NON-PAYMENT OF PREMIUM. See Attachments POLICY NUMBER: GLO 4641358, GLO 1365630 COMMERCIAL GENERAL LIABILITY CG 20 10 04 13 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. 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 AS REQUIRED BY WRITTEN CONTRACT AS REQUIRED BY WRITTEN CONTRACT 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 Attachment Code: D560357 Master ID: 1482179, Certificate ID: 17198398 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. C. With respect to the insurance afforded to these additional insureds, the following is added to Section Ill -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 Units of Insurance shown in the Declarations. Attachment Code: D560357 Master ID: 1482179, Certificate ID: 17198398 BLACK & VEATCH CORPORATION Waiver Of Subrogation (Blanket) Endorsement Policy No.Eff.Date of Pol.Exp. Date of Pol. Eff. Date of End. Producer Add'l. Prem Return Prem. GLO 4641358 11/1/2020 11/1/2021 11/1/2020 GLO 1365630 11/1/2020 11/1/2021 11/1/2020 This endorsement modifies the insurance provided under the following: Commercial General Liability Coverage Part The following is added to the Transfer Of Rights Of Recovery Against Others To Us Condition: If you are required by a written contract or agreement, which is executed before a loss, to waive your rights of recovery from others, we agree to waive our rights of recovery. This waiver of rights shall not be construed to be a waiver with respect to any other operations in which the insured has no contractual interest. Attachment Code: D560353 Master ID: 1482179, Certificate ID: 17198398 POLICY NUMBER: BAP 4641355 (AOS)COMMERCIAL AUTO CA 20 48 02 99 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. DESIGNATED INSURED This endorsement modifies insurance provided under the following: BUSINESS AUTO COVERAGE GARAGE COVERAGE FORM MOTOR CARRIER COVERAGE FORM TRUCKERS COVERAGE FORM With respect to coverage provided by this endorsement, the provisions of the Coverage Form apply unless modified by this endorsement. This endorsement indentifies person(s) or organization(s) who are "insureds" under the Who Is An Insured Provision of the Coverage Form. This endorsement does not alter coverage provided in the Coverage Form. This endorsement changes the policy effective on the inception date of the policy unless another date is indicated below. Endorsement Effective:11/1/2020 Named Insured: BLACK & VEATCH CORPORATION SCHEDULE Name of Person(s) or Organization(s): AS REQUIRED PER WRITTEN CONTRACT (If no entry appears above, information required to complete this endorsement will be shown in the Declarations as applicable to the endorsement.) Each person or organization shown in the Schedule is an "insured" for Liability Coverage, but only to the extent that person or organization qualifies as an "insured" under the Who Is An Insured Provision contained in Section II of the Coverage Form. Attachment Code: D493890 Master ID: 1482179, Certificate ID: 17198398 BLACK & VEACH CORPORATION Waiver of Transfer Of Rights Of Recovery Against Others To Us Policy No.Eff.Date of Pol.Exp. Date of Pol.Eff. Date of End. Producer No. Add'l. Prem Return Prem. BAP 4641355 (AOS) 11/1/2020 11/1/2021 11/1/2020 This endorsement is issued by the company named in the Declarations. It changes the policy on the effective date listed above at the hour stated in the Declarations. THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. Named Insured: OVERLAND CONTRACTING INC. Address (including ZIP code): 600 N GREENFIELD PKWY GARNER NC 27529 This endorsement modifies insurance provided under the: Business Auto Coverage Form Truckers Coverage Form Garage Coverage Form Motor Carrier Coverage Form SCHEDULE Name of the Person or Organization: AS REQUIRED BY WRITTEN CONTRACT We waive any right of recovery we amy have against the designated person or organization shown in the schedule because of payments we make for injury or damage caused by an "accident" or "loss" resulting from the ownership, maintenance, or use of a covered "auto" for which a Waiver of Subrogation is required in conjunction with work performed by you for the designated person or organization. The waiver applies only to the designated person or organization shown in the schedule. Attachment Code: D493897 Master ID: 1482179, Certificate ID: 17198398 Black & Veatch Corporation WC 00 03 13 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.) Effective Policy No. WC 4641353 (AOS), WC 4641354 (ID, MA, WI), WC 1365632, WC 1365631 (NE) Insured: BLACK & VEATCH CORPORATION Effective Date: 11/1/2020 Attachment Code: D560356 Master ID: 1482179, Certificate ID: 17198398