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HomeMy WebLinkAboutCertificate of Liability InsuranceACC•RO® V .. CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DD/YYYY) 9/5/12 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 Arthur J. Gallagher & Co. Insurance Brokers of California, Inc. 505 N. Brand Blvd., Suite 600 Glendale, CA 91203-3944 License No. 0726293 CONTACT NAME: Tara Mitchell PHONE (A/C, No, Ext): (818) 539-1439 ADDRESS: E-MAIL tara mitchell@ajg.com PRODUCER CUSTOMER ID #: FAX (A/C, No): (818) 539-1739 INSURER(S) AFFORDING COVERAGE NAIC # INSURED Fox Entertainment Group, Inc., Twentieth Century Fox Film Corporation, Fox Television Studios, Inc., and their subsidiaries and divisions P.O. Box 900 Beverly Hills, CA. 90213 INSURER A : Travelers Indemnity Company of Connecticut INSURER B: National Union Fire Insurance Co. INSURER C : Travelers Property Casualty Company of America INSURER D : Travelers Indemnity Company INSURER E : U.S. Specialty Insurance Co. 25682 19445 25674 25658 29599 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, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR LTR TYPE OF INSURANCE ADDLSUBR INSR WVD POLICY NUMBER POLICY EFF JMM/DDIYYYY)(MM/DD/YYYY) POLICY EXP LIMITS A GENERAL X LIABILITY COMMERCIAL GENERAL X LIABILITY OCCUR X HC2E-GLSA-470M4037-TCT-12 06/30/2012 06/30/2013 EACH OCCURRENCE $ 2,000,000 DAMAGE TO RENTED PREMISES (Ea occurrence) $ 500,000 CLAIMS -MADE MED EXP (Any one person) $ 10,000 GEN'L X PERSONAL & ADV INJURY $ 2,000,000 GENERAL AGGREGATE $ 15,000,000 AGGREGATE LIMIT APPLIES PRO- POLICY JECT PER: PRODUCTS- COMP/OP AGG $ 2,000,000 LOC $ A E AUTOMOBILE X x X LIABILITY ANY AUTO ALL OWNED AUTOS SCHEDULED AUTOS HIRED AUTOS NON -OWNED AUTOS PHYSICAL DAMAGE X HC2E-CAP-470M4025-TCT-12 HRE-CAP-470M4406-TCT-12 (NY Only) U-11/7001988 06/30/2012 12/01/2011 06/30/2013 04/02/2014 COMBINED SINGLE LIMIT (Ea accident) $ 2,000,000 BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ PROPERTY DAMAGE (Per accident) $ $ PHYSICAL DAMAGE $ INCL. IN MISC EQUIP B x UMBRELLA LIAB EXCESS LIAB X OCCUR CLAIMS -MADE X 13273225 06/30/2012 06/30/2013 EACH OCCURRENCE $ 5,000,000 AGGREGATE $ 5,000,000 DEDUCTIBLE RETENTION $ $ $ C D WORKERS COMPENSATION AND EMPLOYERS' LABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS Y/ N N / A HC2J-UB-470M4001-12 (AOS) HRK-UB-470M4013-12 (AZ, MA, WI) 06/30/2012 06/30/2012 06/30/2013 06/30/2013 WC STATU- OTH- X TORY LIMITS ER E.L. EACH ACCIDENT $ . 2,000,000 W E.L. DISEASE - EA EMPLOYEE $ 2,000,000 below E.L. DISEASE - POLICY LIMIT $ 2,000,000 E THIRD PARTY PROPERTY DAMAGE MISCELLANEOUS EQUIPMENT PROPS/SETS/WARDROBE - U-11/7001988 12/01/2011 04/02/2014 Limit: $5,000,000 Limit: S5,000,000 Limit: $5,000,000• DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES Attach ACORD 101, Additional Remarks Schedule, if more space is required) Certificate Holder is included as an Additional Insured as required by written contract as per blanket Additional Insured endorsements GL 20 34 07 04, CG 20 11 01 96, CG 20 37 07 04 and / or CG 20 15 07 04 and as Loss Payee as their interest may appear, as respects locations, premises, vehicles and/or equipment leased and/or rented by the Named Insured while used in connection with the production entitled: "Burn Notice" Season 6. CERTIFICATE HOLDER CANCELLATION City of Miami 444 Southwest 2nd Avenue Miami, FL 33130 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 © 1988-2009 ACORD CORPORATION. All rights reserved. ACORD 25 (2009/09) The ACORD name and logo are registered marks of ACORD