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). PRODUCER The Buckner Company 6550 South Millrock Dr. Suite #300 Salt Lake City UT 84121 INSURED CONTACT NAME: PHONE (A/C, No, Ext): E-MAIL ADDRESS: INSURER A : INSURER B : INSURER C : INSURER D : INSURER E : INSURER F : INSURER(S) AFFORDING COVERAGE FAX (A/C, No): COVERAGES CERTIFICATE NUMBER: 1953423348 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, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR LTR OTHER: TYPE OF INSURANCE AUTOMOBILE LIABILITY EXCESS LIAB SCHEDULED AUTOS NON-OWNED AUTOS ONLY DED X RETENTION $ 10,000 WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below Y / N N ADDL INSD N / A SUBR WVD POLICY NUMBER POLICY EFF (MM/DD/YYYY) POLICY EXP (MM/DD/YYYY) A X COMMERCIAL GENERAL LIABILITY PHPK1799067 4/1/2018 4/1/2019 EACH OCCURRENCE $ 1,000,000 DAMAGE TO RENTED CLAIMS-MADE X OCCUR PREMISES (Ea occurrence) $ 100,000 OTH- ER GEN'L AGGREGATE LIMIT APPLIES PER: PRO- POLICY X JECT LOC COMBINED SINGLE LIMIT (Ea accident) BODILY INJURY (Per person) BODILY INJURY (Per accident) PROPERTY DAMAGE (Per accident) UMBRELLA LIAB OCCUR PHUB623506 4/1/2018 4/1/2019 EACH OCCURRENCE $ CLAIMS-MADE CERTIFICATE OF LIABILITY INSURANCE MOUNALA-01 Fire Protection Service Corp. dba Mountain Alarm CopperState Fire Protection, Link Interactive, United Systems, Kenco Security and Technology 4155 Harrison Blvd. Ogden UT 84403 A X ANY AUTO OWNED AUTOS ONLY X HIRED AUTOS ONLY X Sandy Reed 801-937-6753 sreed@buckner.com PHPK1799067 4/1/2018 4/1/2019 MED EXP (Any one person) PERSONAL & ADV INJURY GENERAL AGGREGATE AGGREGATE PER STATUTE E.L. EACH ACCIDENT LIMITS PRODUCTS - COMP/OP AGG $ $ 1,000,000 $ E.L. DISEASE - EA EMPLOYEE $ 1,000,000 E.L. DISEASE - POLICY LIMIT $ 5,000 $ 1,000,000 $ 2,000,000 $ 2,000,000 $ $ $ $ 8,000,000 $ DATE (MM/DD/YYYY) 4/11/2018 $ 1,000,000 $ 1,000,000 NAIC # Philadelphia Indemnity Insurance Company 18058 Workers Compensation Fund 10033 Advantage Workers Compensation Ins Co 40517 A X X 8,000,000 B C 1193323 2224949 4/1/2018 4/1/2018 4/1/2019 4/1/2019 A Errors & Omissions PHPK1799067 4/1/2018 4/1/2019 $1,000,000 Limit X DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) General Liability has a $1,000 Bodily Injury Deductible and a $1,000 Property Damage Deductible. The Errors & Omissions Policy is covered under the Umbrella Policy. Additional Insured with respect to the General Liability per form PI-GLD-SG(01/14) including products and completed operations per form CG2037 04/13. Coverage is primary and non-contributory per form PI-GL-005 (07/12). Waiver of subrogation per form PI-GLD-SG(01/14). Auto Additional Insured per form CA20480299. Auto waiver of subrogation per form CA04440310. Work Comp waiver of subrogation per form WC400305. Umbrella follows form. Cancellation per form #PI-CANXAICH-002(05/11). CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. FOR INFORMATION ONLY AUTHORIZED REPRESENTATIVE ACORD 25 (2016/03) 1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD
PI-CANXAICH-002 (05/11) THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. CANCELLATION NOTICE TO SCHEDULED ADDITIONAL INSURED OR CERTIFICATE HOLDER This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART PROFESSIONAL LIABILITY COVERAGE PART COMMERCIAL CRIME COVERAGE PART COMMERCIAL INLAND MARINE COVERAGE PART COMMERCIAL PROPERTY COVERAGE PART COMMERCIAL AUTOMOBILE COVERAGE PART SCHEDULE OF ADDITIONAL INSUREDS OR CERTIFICATE HOLDERS AI or CH Additional Insured or Certificate Holder Address AI Blanket Additional insured where written contract is required The following is added to A. CANCELLATION of the Common Policy Conditions of the above applicable coverage part: A. In the event we cancel the policy in accordance with the policy s terms and conditions, we will endeavor to mail written notice of cancellation to Additional Insureds or Certificate Holders, shown in the above SCHEDULE within the time frame listed below. However, failure to mail such notice shall impose no obligation of any kind upon us, our agents or representatives. 1. 30 days before the effective date of cancellation if we cancel for any reason other than for non - payment of premium. As respects Additional Insureds, the above cancellation provision applies only when the Additional Insured shown in the above SCHEDULE is added to the policy by a separate additional insured endorsement as the CANCELLATION NOTICE TO ADDITIONAL INSURED OR CERTIFICATE HOLDER does not provide additional insured coverage. Page 1 of 10
PHPK1799067
WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 00 03 13 WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT (Ed. 4-84) 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 A blanket waiver of subrogation is granted for all projects and contracts for the below named insured and its subsidiaries for all jobs requiring such a waiver in writing in all states listed under section 3A of your information page. 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.) Endorsement Effective: 04/01/2017 04/01/2018 Policy No. 2224949 Endorsement No. N/A Insured: CopperState Fire Protection PO BOX 12487 Ogden UT 84412 Premium Insurance Company Countersigned by Advantage Workers Compensation Insurance Company WC 00 03 13 (Ed. 4-84) 1983 National Council on Compensation Insurance.
Policy #PHPK1799067 04/01/2018
PHPK1799067 04/01/2018
PHPK1799067 04/01/2018
Policy #PHPK1799067