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HomeMy WebLinkAboutInsurance Certificate: Grayback Forestry AcOR°® CERTIFICATE OF LIABILITY INSURANCE DATE (MM DDYYYy) 12/6/2012 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 endorsements . PRODUCER CONTACT NAME: KPD Insurance, Inc. PMONE MC N,541-741-1-674 Eldl PO Box 784 E-MAIL 541-741-0550 Springfield OR 97477 ADDRESS: INSURERS AFFORDING COVERAGE NAIC0 INSURERA:$AIF CQrpcr1 -1. INSURED GRAY03W INSURERS: rl h Ame l an sI rrance_CD. Grayback Forestry, Inc. INSURER C : PO Box 838 Merlin OR 97532 INSURER D: INSURER E INSURER F : COVERAGES CERTIFICATE NUMBER: 1058340096 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. DL SUSA ILTR TYPE OF INSURANCE ~R MO POLICY NUMBER MMIDDNYY MMDDY/YYYY LIMITS GENERAL LIABILITY EACH OCCURRENCE $ COMMERCIAL GENERAL LIABILITY DAMAGE TOR NTED PREMISES E. occunenca $ CLAIMS-MADE OCCUR MED EXP(Any one person) $ PERSONAL S ADV INJURY S GENERAL AGGREGATE $ GEN'L AGGREGATE LIMIT APPLIES PER PRODUCTS - COMP/OP AGG S POLICY J'R'0T F-] LOC $ AUTOMOBILE LIABILITY CEO OSINED SINGLE LIMIT ANY AUTO, BODILY INJURY (Per person) $ ALL OWNED SCHEDULED BODILY INJURY Per accident $ AUTOS AUTOS ( ) NOfW WNED PROPERTY DAMAGE HIRED AUTOS AUTOS Per eoddent S I H T S UMBRELLA LIAR OCCUR EACH OCCURRENCE $ EXCESS LIAB co:, -MADE AGGREGATE $ DED RETENTIONS $ A WORKERS COMPENSATION 5606-OR 1/12013 1/1/2014 X WC STATU- OTH- A AND EMPLOYERS' UABILTY YIN 3584-OR 1/1/2013 1/1/2014 ORUW ANY PROPRIETORIPARTNERIEXECUTIVE E.L. EACH ACCIDENT $500,000 OFFICERMIEMBER EXCLUDED? NIA (Mandatory In NH) E.L.DISEASE - EA EMPLOYE $500,000 ups Cescribeunder DCRIPTION OF OPERATIONS biii. E.L. DISEASE-POLICYLIMIT $500,000 B Workers Compensation C9663291 (MULTI STATE) 111/2013 /1/2014- EL Each Accident $1,000,000 and Employers Liablity Limits EL Disease EA $1,000,000 EL Disease Policy $1.000,000 DESCRIPTION OF OPERATIONS / LOCATIONS I VEHICLES (Attach ACORD 101, Additional Remarks Schedule, If more apace Is required) Re: All Operations D CEC IEUMCE CERTIFICATE HOLDER CANCELLATION U UL- SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN CityOf Ashland ACCORDANCE WITH THE POLICY PROVISIONS. 20 East Main Str Ashland OR 97520 AUTHORIZED REPRESENTATIVE ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25 (2010/05) The ACORD name and logo are registered marks of ACORD