HomeMy WebLinkAboutInsurance Certificate: VSS Emultech
BASIC-1 OP ID: MY
(MWDD
1121191IYYYY)
`aka R CERTIFICATE OF LIABILITY INSURANCE 0 DAT2
09/13
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 endorsemen s .
PRODUCER CONTACT
Phone: 650-573-1111 NAME:
Andreini & Company-San Mateo .4361 PHONE FAX
License 02088Fax: 650-378 AIC No Em, VC No :
220 West 20th Ave ADDRESS:
San Mateo, CA 94403 ADDRESS:
Mike Brunn INSURER(S) AFFORDING COVERAGE NAIC0
INSURER A: National Union Fire Ins Co PA 19445
INSURED Valley Slurry Seal Company INSURER B: Starr Indemnity & Liability Co 38318
dba: VSS Emultech INSURER C: State Compensation-Oregon
3785 Channel Drive
West Sacramento, CA 95691 INSURER D:
INSURER E :
INSURER F
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 TYPE OF INSURANCE ADDL SURF POLICY EFF POLICY EXP
LTR POLICY NUMBER MWO MWD LIMITS im J= GENERAL LIABILITY EACH OCCURRENCE $ 2,000,00
A X COMMERCIAL GENERAL LIABILITY GL6988529 03101113 03101/14 PREMISES Ea occurrence $ 4,006,99
CLAIMS-MADE ~ OCCUR MED EXP (My one poraon) $ 4,000,00
X Deduc$1,000,000 PERSONAL It ADV INJURY $ 10,00
X OCIP Excluded GENERAL AGGREGATE $ 2,000,00
GENT AGGREGATE LIMIT APPLIES PER PRODUCTS - COMP/OP AGO $ 100,08
X PRO- LOC
POLICY IFCT F-1
AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT - 21000100C
Ee accident
A X ANY AUTO CAI 707496 03101113 03101114 BODILY INJURY (Per Person) E
ALL OWNED SCHEDULED BODILY INJURY (Per accident) $
AUTOS AUTOS
X HIRED AUTOS X NON-OWNED PROPERTY DAMAGE $
AUTOS Per accident
X Deduc Simon X OCIP Eaclu MCS 90 $ Include
UMBRELLA LUIS X OCCUR EACH OCCURRENCE $ 5,000,00
B X EXCESS LIAB CLAIMS-MADE SISCCCLOO006512, 03101113 03101114 AGGREGATE E 5,000,00
DED RETENTION$ $
WORIERS COMPENSATION WC STATU- OTH-
AND EMPLOYERS' LIABILITY I TORY LIMITS ER
C ANY PROPRIETORMARTNERIEXECUTNE YIN 97123 - OREGON 04101112 04101113 E.L. EACH ACCIDENT E
OFFICERNEMBER EXCLUDED? ❑ NIA
(Mandatory In NH) E.L. DISEASE-EA EMPLOYEE $
0 yes, aescrioe under
DESCRIPTION OF OPERATIONS Wox E.L. DISEASE -POLICY LIMIT E
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101, Additional Remade Schedule, H mom apace Is requlre0) D P= G
1`l:/w [92 0 V Le
l
F E B 2 5 2013
CERTIFICATE HOLDER CANCELLATION
ASHASHI
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
City of Ashland ACCORDANCE WITH THE POLICY PROVISIONS.
20 East Main Drive
Ashland, OR 97520 AUTHORIZED REPRESENTATNE
®1988-2010 ACORD CORPORATION. All rights reserved.
ACORD 25 (2010105) The ACORD name and logo are registered marks of ACORD