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Home My WebLink AboutSKMBT_C35113042510220AC;URDTM CERTIFICATE OF LIABILITY INSURANCE DA DD/YYYY) 7/1/2013 8/1 0/ 0/2012 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 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 Lockton Companies, LLC Denver CONTACT N AME: 8110 E Union Avenue PHONE FAX S i 70 A /C, No, Ext : A/C No): u te 0 Denver CO 80237 E-MAIL ADDRES : (303) 414-6000 INSURER AFFORDING COVERAGE NAIC # INSURER A : National Union Fire Ins Co Pittsburgh PA 19445 INSURED Labor Ready INSURER B : New Hampshire Insurance Company 23841 1036748 (See Attached Named Insured Schedule) 1015 A Stre t INSURER C : Insurance Company of the State of PA 19429 e PO Box 2910 INSURER D : Tacoma, WA 98401 INSURER E : 697444 INSURER F i 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. INSR LTR TYPE OF INSURANCE ADDL INSR SUBR wVD POLICY NUMBER POLICY EFF MM/DD/YYYY POLICY EXP MM/DD/YYYY LIMITS A GENERAL LIABILITY N N 4406477 7/1/2012 7/1/2013 EACH OCCURRENCE 1,000,000 X COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED PREMISES Ea occurrence 4_,1000,000 CLAIMS-MADE a OCCUR MED EXP An one person) XXXXXXX X Host Liquor $1 M PERSONAL & ADV INJURY $ 1,000,000 X SIR $1 M GENERAL AGGREGATE $ 5,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP/OP AGG $ 3,000,000 X POLICY JECT LOC $ A AUT OMOBILE LIABILITY N N 4982855-AOS 7/1/2012 7/1/2013 Ee acccidentSINGLE LIMIT $ 1 000 000 A X ANY AUTO 4982856-VA 7/1/2012 7/1/2013 BODILY INJURY (Per person) , , $ XXXXXXX AUTOS~ED AUTOSULED BODILY INJURY (Per accident $ XXXXXXX HIRED AUTOS AUUTOS NO-WNED PROPERTY DAMAGE Per accident $ XXXXXXX $ XXXXXXX A UMBRELLA LIAB X OCCUR N N 13273257 7/1/2012 7/1/2013 EACH OCCURRENCE $ 5 000 000 EXCESS LIAB CLAIMS-MADE AGGREGATE , , $ 5,000 000 DED RETENTION $ , $ XXXXXXX B WORKERS COMPENSATION AND EMPLOYERS' LIABILITY YIN Y 061967959-AOS; 06 1 96795 1-C 7/l/2012 7/1/2013 WC STATU- OTH- X TORY LIMITS FIR B C ANY PROPRI I OFFICER/MEMBER EXCLUDED? R/PARTNER/EXECUTIVE B N/A 061967953-FL; 061967962-MN 061967955-OR; 061967960-MA 7/l/2012 7/1/2012 7/1/2013 7/1/2013 E.L. EACH ACCIDENT $ 10000 00 (Mandatory in NH) If es describe nd E.L. DISEASE - EA EMPLOYEE 1,000,000 y , u er DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT 1,000,000 A Excess Work Comp N N 1 19251 1-QSI 7/1/2012 7/1/2013 WC - Statutory; EL Limit $1,000,000 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES /(Attach ACORD 101, Additional Remarks Schedule, if more space is required) The above coverages apply only to Temporary Labor Ready employees dispatched to do work on behalf of the Certificate Holder. Waiver of Subrogation applies on Workers Compensation per written contract. CERTIFICATE HOLDER CANCELLATION See Attachmentq 11950842 Town of Tiburon 1505 Tiburon Blvd. Tiburon, CA 94920 ACORD 25 (2010/05) SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE j r1 9 #~/L IV/ @198812010 ACORD CORPO TION. All rights reserved Tho Arr)pn namo onri Innn 2ro ronia*oraA m:arlea of Art-ip , SCHEDULE OF NAMED INSUREDS Labor Ready Affiliates' States of Operation Please refer to the chart below to find the Labor Ready entity Named Insured for the state in which temporary workers are dispatched to work. Labor Ready Entity Labor Ready Northeast, Inc. Labor Ready Southeast, Inc Labor Ready Mid-Atlantic, Inc Labor Ready Central, Inc. Labor Ready Midwest, Inc Labor Ready Northwest, Inc Labor Ready Southwest, Inc. Labor Ready, Inc. Labor Ready Holdings, Inc. Spartan Staffing, LLC Spartan Staffing Puerto Rico, LLC PTPR, Inc. Job Rooster, Inc. Centerline Drivers, LLC Venue Ready, LLC PlaneTechs, LLC Drivers on Demand, LLC TrueBlue Enterprises, Inc. TrueBlue Inc. PAC States of Operation Connecticut, Maine, New Jersey, Delaware, Maryland, New York, District of Columbia, Massachusetts, Pennsylvania, Rhode Island, New Hampshire, Vermont Alabama, Kentucky, Louisiana, Georgia, Mississippi, Florida Indiana, Ohio, Virginia, North Carolina, South Carolina, West Virginia, Tennessee Arkansas, Missouri, Texas, Colorado New Mexico, Wyoming, Kansas, Oklahoma Illinois, Minnesota, South Dakota, Iowa, Nebraska, Wisconsin, Michigan, North Dakota Alaska, Montana, Oregon, Hawaii, Washington, Idaho Arizona, Utah, California, Nevada Miscellaneous Attachment : M19451 Master ID: 1036748, Certificate ID: 11950842 BLANKET WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT This endorsement changes the policy to which it is attached effective on the inception date of the policy unless a different date is indicated below. (The following "attaching clause" need to be completed only when this endorsement is issued subsequent to preparation of the policy). This endorsement, effective 12:01 AM 07/01/2012 forms a part of Policy No. WC 061967951 Issued to: Labor Ready Northeast, Inc.; Labor Ready Southeast, Inc.; Labor Ready Mid- Atlantic, Inc.; Labor Ready Central, Inc.; Labor Ready Midwest, Inc.; Labor Ready Northwest, Inc.; Labor Ready Southwest, Inc.; Spartan Staffing, LLC; PlaneTechs, LLC; Centerline Drivers, LLC; & Venue Ready, LLC By The New Hampshire Insurance Company We have a right to recover our payments from anyone liable for an injury covered by this policy. We will not enforce our right against any person or organization with whom you have a written contract that requires you to obtain this agreement from us, as regards any work you perform for such person or organization. This additional premium for this endorsement shall be 2% of the total estimated workers compensation premium for this policy. WC 04 03 61 (Ed. 11/90) Miscellaneous Attachment : M69568 Certificate ID : 11950842