ML16349A092

Certificate of Liability Insurance

ML16349A092
Person / Time
Site:	Monticello, Prairie Island
Issue date:	11/28/2016
From:	Mukherjee M Marsh USA
To:	Document Control Desk, Office of Nuclear Reactor Regulation
References
Download: ML16349A092 (4)

Text

0002433 SP 0722' -C01-P02434-I Document Control Desk .

U.S. Nuclear Regulatory Commlssion.:1:

~a_, 2<izj3o(p Washington, DC 20555c0001 5tJ -Zb ~

DATE (MM/DDNYYY)

ACORD

~-

CERTIFICATE OF LIABILITY INSURANCE THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS I 11/28/2016 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 CONTACT NAME:

Marsh USA Inc.

333 South 7th Street, Suite 1400 PHONE IA/C No Extl' I FAX Nol:

IA/C Minneapolis, MN 55402-2400 E-MAIL ADDRESS:

INSURER(S) AFFORDING COVERAGE NAIC#

-NUCLR-16-17 INSURER A : American Nuclear Insurers INSURED INSURER B:

Xcel Energy, Inc.

ATIN: Robert Miller INSURERC:

414 Nicollet Mall, 4th Floor INSURERD:

Minneapolis, MN 55401 INSURER E:

INSURER F:

COVERAGES CERTIFICATE NUMBER: CH 1-005576857-10 REVISION NUMBER:11 THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD 1*

INDICATED. N01WITHSTANDING 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.

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INSR ADDL SUBR POLICY EFF POLICY EXP LTR TYPE OF INSURANCE COMMERCIAL GENERAL LIABILITY

• • • <m "Mn POLICY NUMBER IMM/DDNYYYI IMM/DDNYYYl EACH OCCURRENCE LIMITS

• "::~J I CLAIMS-MADE D OCCUR DAMAGE TO RENTED PREMISES IEa occurrence) $ ..*,;:::1.:

MED EXP (Any one person) $ ..  :~~*:i:

PERSONAL & ADV INJURY $ ~j~h:~

GEN'L AGGREGATE LIMIT APPLIES PER: GENERALAGGREGATE $

~ POLICY DPRO- JECT DLOC PRODUCTS - COMP/OP AGG $

OTHER: $

AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $

- IEa accidentl ANY AUTO BODILY INJURY (Per person) $

ALL OWNED - SCHEDULED AUTOS AUTOS BODILY INJURY (Per accident) $

- - NON-OWNED PROPERTY DAMAGE HIRED AUTOS rPer accidenll $

- - AUTOS H

UMBRELLA LIAB EACH OCCURRENCE $

- OCCUR EXCESSLIAB CLAIMS-MADE AGGREGAJE $

OED I I RETENTION $ $

WORKERS COMPENSATION AND EMPLOYERS' LIABILITY I PER STATUTE I I OTH-ER Y/N ANY PROPRIETOR/PARTNER/EXECUTIVE E.L. EACH ACCIDENT

~

OFFICER/MEMBER EXCLUDED? N/A (Mandatory in NH) E.L. DISEASE - EA EMPLOYEE $

If yes, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT $

A Nuclear Energy Liability 'See Attached ACORD 101' 01/01/2017 01/01/2018 See Attached ACORD 101 Insurance DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached If more space Is required)

CERTIFICATE HOLDER CANCELLATION Document Control Desk SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE U.S. Nuclear Regulatory Commission THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Washington, DC 20555-0001 ACCORDANCE WITH THE POLICY PROVISIONS.

AUTHORIZED REPRESENTATIVE of Marsh USA Inc.

I Manashi Mukherjee ...l°'t.A~ ..... ~

© 1988-2014 ACORD CORPORATION. All rights reserved.

ACORD 25 (2014/01) The ACORD name and logo are registered marks of ACORD

AGENCY CUSTOMER ID:~~~~~~~~~~~~~~~~~~~

LOC #: Minneapolis ADDITIONAL REMARKS SCHEDULE Page 2 of 3 AGENCY NAMED INSURED Marsh USA Inc. Xcel Energy, Inc.

ATIN: Robert Miller POLICY NUMBER 414 Nicollet Mall, 4th Floor Minneapolis, MN 55401 CARRIER I NAICCODE EFFECTIVE DATE:

ADDITIONAL REMARKS THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, FORM NUMBER: 25 FORM TITLE: Certificate of Liability Insurance

~~~~~~~========-_..'.....:~~~==:.....::================~==========================================================~ ...

i J

CERTIFICATE OF NUCLEAR ENERGY LIABILITY INSURANCE , 1 **

This is to certify that there is in force as of the effective date of this Certificate a Nuclear Energy Liability Insurance Policy issued by members of American Nuclear Insurers as indicated {Companies}, to the Insured named herein, with respect to the Nuclear Facility at the Location shown and/or with respect to the lnsured's operations described herein. If *1 such policy is cancelled or otherwise terminated prior to the end of December 31st of the calendar year in which the Effective Date of this Certificate occurs, notice will be delivered in accordance with the policy provisions. Otherwise this Certificate shall terminate as of the end of such December 31st. A Certificate will NOT be issued for any subsequent calendar year unless requested in writing.

I

.r Types of Insurance: NF - [Facility Form], NW- [Master Worker Certificate], NS - [US Domestic Supplier's & Transporters], FS - [Foreign Suppliers & Transporters]

COVERAGE FOR NUCLEAR FACILITIES:

r~:  ;

1. SITE #1 - PRAIRIE ISLAND LOCATION OF NUCLEAR FACILITY: Prairie Island Nuclear Power Plant on the Mississippi River in Goodhue County, Minnesota NAMED INSURED [LISTED ON POLICY]: Northern States Power Company POLICY NUMBER: POLICY EFFECTIVE: LIMIT OF LIABILITY:

NF-0197 09/01/1971 $450 Million NW-0580 09/01/1971 $450 Million"

2. SITE #2- MONTICELLO LOCATION OF NUCLEAR FACILITY: Monticello Nuclear Power Plant on the Mississippi River in Wright County, Minnesota NAMED INSURED [LISTED ON POLICY]: Northern States Power Company POLICY NUMBER: POLICY EFFECTIVE: LIMIT OF LIABILITY:

NF-0174 06/09/1969 $450 Million NW-0564 06/09/1969 $450 Million"

3. SITE #3- PATHFINDER LOCATION OF NUCLEAR FACILITY: Pathfinder Atomic Nuclear Power Plant {Shutdown 9/16/67) in Minnehaha County, South Dakota NAMED INSURED [LISTED ON POLICY]: Northern States Power Company POLICY NUMBER: POLICY EFFECTIVE: LIMIT OF LIABILITY:

NF-0106 04/27/1961 $5 Million NW-0531 04/27/1961 $450 Million**

COVERAGE FOR SUPPLIER'S & TRANSPORTER'S:

4. US DOMESTIC S&T DESCRIPTION OF OPERATIONS: Furnishing of services, materials, parts or equipment in connection with the planning, construction, maintenance, involving the handling, storage, shipment, use or disposal of specified types of nuclear materials.

NAMED INSURED [LISTED ON POLICY]: Xcel Energy, Inc.

POLICY NUMBER: POLICY EFFECTIVE: LIMIT OF LIABILITY:

NS-0474 09/01/1985 $450 Million THIS CERTIFICATE IS ISSUED AS A MATIER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.

The insurance afforded by the policy(ies} is subject to the exclusions, conditions and other provisions of the policy(ies}. Neither this Certificate nor any contract or other document with respect to which it is issued shall amend, extend or alter the coverage afforded by the policy. The Limit of Liability shown above may have been reduced by payment of claims

• or claims expenses.

ACORD 101 (2008/01) © 2008 ACORD CORPORATION. All rights reserved.

The ACORD name and logo are registered marks of ACORD

AGENCY CUSTOMER ID: ~~~~~~~~~~~~~~~~~~~~

LOC #: Minneapolis ADDITIONAL REMARKS SCHEDULE Page 3 of 3 AGENCY NAMED INSURED Marsh USA Inc. Xcel Energy, Inc.

ATTN: Robert Miller POLICY NUMBER 414 Nicollet Mall, 4th Floor Minneapolis, MN 55401 CARRIER I NAICCODE EFFECTIVE DATE:

ADDITIONAL REMARKS THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, FORM NUMBER: 25 FORM TITLE: Certificate of Liability Insurance COMMENTS/NOTES:

H Master Worker Certificate - This limit is shared by all Certificates to the Master Worker Policy of which each Certificate is a part and is subject to all of the provisions of such Policy and Certificate having reference thereto. Such limit may have been reduced by payment of claims or claims expenses.

.t I

~- - I ACORD 101 (2008/01) © 2008 ACORD CORPORATION. All rights reserved.

The ACORD name and logo are registered marks of ACORD