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HomeMy WebLinkAboutInsurance Certificate: Potelco Inc CITY RECORDER DAM(MMIDDIYYYYI A�° CERTIFICATE OF LIABILITY INSURANCE 1 7/1612012 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 ,john L. Wortham & Son, L.P. CONTACT NAME: P. O. Box 1388 PHONE FAXIAC.N.): Z13-521-1951 Houston, TX 77251-1388 E-MAIL ADDRESS: INSURER(S) AFFORDING COVERAGE NAIC0 INSURER A: Old Republic Insurance Company 24147 INSURED INSURER B: Ace Propedy&Casualty Insurance Co. 20699 Potelco Inc. 14103 Stewart Rd. INSURER C: Sumner WA 98390 INSE D INSURURER R E: INSURER F: COVERAGES CERTIFICATE NUMBER: 13624381 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 TYPE OF INSURANCE JOB SUBR POUCYNUMBER MMIDDYIYYYFY MMIDDIYYYY LIMITS LTR A GENERAL LIABILITY MWZY59816 811/2012 8/1/2013 EACH OCCURRENCE $ 5,000,000 ✓ COMMERCIAL GENERAL LIABILITY PREMISES EeEPOOUnence $ 5,0()0,000 CLAIMS-MADE ©OCCUR MED EXP(My one Pe.) $ excluded PERSONAL&ADV INJURY $ 5,000,000 GENERALAGGREGATE a 5,000,000 GEN'L AGGREGATE LIMIT APPLIES PER PRODUCTS-COMPIOP AGO $ 5,000,000 POLICY P" LOC $ A AUTOMOBILE LIABILITY MWTB21639 8/1/2012 811/2013 Ea COMBINED SINGLE LIMIT E 5000000 ✓ ANY AUTO BODILY INJURY(Par Person) $ ALL OWNED SCHEDULED BODILY INJURY(Per accident) $ ✓ AUTOS AUTOS NON-OWNED PBOPPEERdB t AMAGE $ ✓ HIRED AUTOS AUTOS s S B UMBRELLA UAB OCCUR XOOG25909914 8/1/2012 6/112013 EACH OCCURRENCE $ 5,000,000 EXCESS LIMB ,/ CLAIMS-MADE AGGREGATE $ 5,000,000 DEO RETENTION$per policy CM Retro Date 8/112002 $ a $ A WORKERS COMPENSATION MWIC11792700 8/1/2012 8/112013 NC STATU- O AND EMPLOYERS'LIABILITY YIN ORY LIMITS ANY PROPRIETOMPARTNENEXECL'TIVE NIA E.L.EACH ACCIDENT $ 1000000 OFFICEWMEMBER EXCLUDED? (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $ 1000000 If yes,DESCRIPTION E.L.DISEASE-POLICY LIMIT $ 1,000,000 DESCRIPTION under OPERATIONS belax DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (Attach ACORD 101,Additional Remarks Schedule,It more space Is mqulmd) Re: All Operations General Liability And Auto Liability Policies Include The City Of Ashland,Oregon,And Its Elected Officials,Officers And Employees As An Additional Insured When Required By Written Contract But Only As Respects Liability Arising Out Of Named Pnsured's Work For Additional Insured. - CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE The City Of Ashland, Oregon THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Attn: Kari Ann Olson ACCORDANCE WITH THE POLICY PROVISIONS. 90 N. Mountain Ave. Ashland OR 97520 AUTHORIZED REPRESENTATIVE John L.Wortham&Son,L.P. ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010105) The ACORD name and logo are registered marks of ACORD CERT NO.: 13624381 CLIENT CODE: 1000MTSER (HOU) Sandy Moore 7/16/2012 4:45:06 PM Page 1 of 2 AGENCY CUSTOMER ID: 10QUANTSER LOC#: ADDITIONAL REMARKS SCHEDULE Page _of AGENCY NAMED INSURED John L.Wortham Potelco Inc.&Son,L.P. 14103 Stewart Rd. POLICY NUMBER Sumner WA 98390 CARRIER NAIC CODE EFFECAVE DATE: ADDITIONAL REMARKS THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, FORM NUMBER: 25 FORM TITLE:Certificate of Liability(05/10) CERTIFICATE HOLDER: The City Of Ashland,Oregon Aftn: Karl Ann Olson ADDRESS: 90 N.Mountain Ave.Ashland OR 97520 General Liability policy includes aggregate limits of insurance per project subject to a maximum policy aggregate of $20, 000,000. ACORD 101 (2008/01) ©2008 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD ATTACHMENT DEPT NO.: 13614361 CLIENT CODE: 1000WPSER (HOU) Sandy Moore ]/16/2012 4:45:06 PM Page 2 of 2