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Home My WebLink About2013-117 License - Ambulance Operators i Yi r1 r0~- ' NI YVY hVl F, 1( Q((( ))I C I T Y O F I G SO) , ASHLAND u(t(~~;y ~ ?crc~, V( Ambulance Operator's License J atai~i~ License issued to: City of Ashland Fire and Rescue Department Licensee has met all requirements of AMC Chapter 6.40 f(Of? License expires June 30, 2014 7 Date Barbara Christensen, City Recorde'r/Treasurer py~r I I CITY OF ASHLAND APPLICATION FOR AMBULANCE OPERATOR LICENSE AMC Ch. 6. 6.40 2013 Applicant's Name: CITY OF ASHLAND Trade Name, if any: ASHLAND FIRE & RESCUE Address: 455 Siskiyou Boulevard Ashland OR 97520 Telephone number: 541 482-2770 Ambulance descriptions Manufacturer Vin # License # 1. 1996 FORD LIFELINE 1FDKE30F8THA48282 EXEMPT 2. 1998 FORD LIFELINE 1FDXE40F2XHAO0469 EXEMPT 3. 2003 FORD LIFELINE 1FDXF47F63EA10341 EXEMPT 4. 2006 FORD LIFELINE 1FDXF47P06ED06467 EXEMPT 5. 2008 FORD LIFELINE 1FDXF47R48ED90832 EXEMPT 6.2011 FORD LIFELINE 1FDUF4HTOBEC53861 EXEMPT ❑ Attach information showing that every proposed driver, attendant and driver- attendant is qualified as required in Ashland Municipal Code Chapter 6.40 and as required by the laws of the State of Oregon. ❑ Enclose with the application, the initial license fee of $300 plus $100 per ambulance. ❑ Enclose a performance bond in the amount of $500,000. ❑ Enclose an insurance policy meeting the requirements of AMC §6.40.110.7. Attach additional pages as necessary. Explain any box not checked. Submit your application and required enclosures to Barbara Christensen, City Recorder, City Hall, 20 East Main Street, Ashland, Oregon 97520. I certify that each ambulance listed above is adequate and safe for the purposes for which it is to be used and that it is equipped as required by Ashland Municipal Code Chapter 6.40 and the laws of the State of Oregon. Signature: Print name: Greg I. Case Title: Division Chief Date: 05-23-2013 C:\Documents and Settings\christeb\Local Settings\Temporary Internet Files\Content.Outlook\9EP3HFQB\2013 lic renewal.doc April 10, 2009 CITY OF ASHLAND Memo DATE: 5-23-2013 TO: Cindy Hanks CC: Barbara Christensen, City Recorder FROM: Greg I. Case, Fire Dept - Division. Chief RE: Renewal of City of Ashland Ambulance Operator License Fee Cindy, It is time once again for our ambulance renewal and a check must accompany our Ambulance license renewal. Could you do an inter-departmental transfer or Check for the Ambulance Licensing Fees From the EMS account # 110.07.13.00.604160 to the City of Ashland accounts receivable. It needs to be included in the renewal Application for Ambulance Operators License that includes the required certifications and documentation required by the AMC 6.40. the Chief has sent the Memo to Dave and a Council Communication requesting ambulance license renewal and is not yet scheduled for a council meeting. As in the past the fees and bond have just been charged to our budget - let me know if this is still correct: Should you need any other information please let me know and I will get it to you as soon as possible. Thank you! Ashland Fire 8. Rescue Tel: 541-482-2770 - 455 Sisk'ryou Blvd. Fax: 541-488-5318 TA Ashland, Oregon 97520 TTY: 800-735-2900 v .ashland.or.us CENTERS FOR MEDICARE & MEDICAID SERVICES CLINICAL LABORATORY IMPROVEMENT AMENDMENTS (y~{y ® pip CERTIFIG4 TE OF WAIVER ASHLAND FIRE iX hESCUE DRESS CLIA ID NUMBER 4 LABOTATORY 38DO866813 455 SISKIYOU BLVD ASHLAND, OR 97520 EFFECTIVE DATE 01/0112012 ~ LABORATORY DIRECTOR, EXPIRATION DATE >p GREG I CASE 12131/2013 Pursuant to Section 353 of the Public Health Services Act (42 U.S.C. 263.) as revisd by the Clinical Laboratory Improvement Amendments (CIIA), the above earned laboratory located at die address shown hereon (and other approved locations) may accept bwnvn specimens for the purposes of performing laboratory examinations or procedures. Thu ceitifi,an shall be valid until the erpiratioa date above, but is subjm to revocation, smp.i., limitation, rather smctionr 'for violation of the Act or the regulations ptomdgated ihetennder. a 91- 4 CMS Judith A. rant, Director a ✓ - Divuion of Laboratory Services ommyamuaa.,mrwunm Survey and Certification Group Center for Medicaid and State Operations • If this is a Certificate of Registration. it represents only the enrollment of the laboratory in the CLIA program and does not indicate a Federal certification of compliance with other CLIA requirements. The laboratory is permitted to begin testing upon receipt of this certificate, but is not determined to be in compliance until a survey is successfully completed. • If this is a L;Ujificate for Provider-Performed Microscopy Procedures, it certifies the laboratory to perform only those laboratory procedures that have been specified as provider-performed microscopy procedures and, if applicable, examinations or. procedures that have been approved as waived.teats by the Department of Health and Human Services. • If this is a Certificate of Waiver, it certifies the laboratory to perform only cauininations or procedures that have been approved as waived tests by the Department of Health and Human Services. .c1_ t _ l,Sv Y r FOR MORE. INFORMATION ABOUT CLIA, VISIT OUR WEBSITE AT W W W.CMS.HHS.GOV/CLIA OR CONTACT YOUR LOCAL STATE AGENCY. PLEASE SEE TI1E REVERSE FOR YOUR STATE AGENCY'S ADDRESS AND PHONE NUMBER. PLEASE CONTACT YOUR STATE AGENCY FOR ANY CHANGES TO YOUR CURRENT CERTIFICATE. .,AUDIT No OREGON HEALTH AUTHORITY t t EMERGENCY,MEDICAL SERVICES & TRAUMA SYSTEMS PROGRAM 47418> LICENSE NUMBER Y # 4 j, x,^9244394 PAYMENT $o EoOD EXPIRATION VIN 20111FDUF4HTOBEC53861'"' ~ ~ ~ ~ ~s ~ MD DonY vR Ir i 'n r h(t"i i 1~ IS> i ti 06/30/2014 r e: ? AMBULANCE LICENSE POST IN VEHICLE City of Ashland #1501 h / ' 455':Slsklyou Blvd 4 I i" `ADMINISTRATOR _ f Ashland OR 97520 \ , x r 5; .x 5 4t OREGON HEALTN AUTHORITY w t MUST BE POSTED IN A CONSPICUOUS PLACE - NOT TRANSFERABLE'f'ti 9 r"s'?J OREGON HEALTH AUTHORITY .AUDRNO c EMERGENCY;MEDICALSERVlCES & TRAUMA SYSTEMS PROGRAM ' ' 47417 a , s- CICENSE o r "a E244388 , PASMr 80.0C VIN i a EXPIRATION K20081FDXF47R48ED90832" ' ` DATE 1 ,S ? ''i x t a ; .'}t a r ✓4 , MO DAY YR >41 x r t w y f t s,.Y ; ei C 06/30!2014 ;AMBULANCE LICENSE POST IN VEHICLE _ City of Ashland #1501 t ar 455'.$ISkIyOU. BIVd 'ADMINISTRATOR !6 r; 1 O HEALTH AUTHORITY Ashland OR 97520 REGON v , L MUST BE POSTED IN A CONSPICUOUS PLACE - NOT TRANSFERABLE OREGON HEALTH AUTHORITY AUDIT NO. EMERGENCYMEDICAL SERVICES & TRAUMA SYSTEMS PROGRAM Y 47415 (LICENSE NUMBERXf } ti k y t' y r^,` Y~,t X. a ` E33465 „r r 80 OD PAVMEM RECEIVED f EXPIRATION VIN~20061FDXF471`06ED06467'-DATE J r 5~ ~vo l II r r ! } S s< ! ! 4i+.`'~ MO DAY YR r F f' 06/30/2014 ,`AMBULANCE LICENSE POST IN VEHICLE uja q H U ,v as gst')'c , City Of Ashland #1501 455:SISkryou Blyd ADMINISTRATOR "Ashland OR 97520 `n \1 ' DREGONHEALTH AU ORITI' 5 ` .s i a 1 f , k' .f, a i _ rr F .D Y ry ~ X x 2~ _c,, MUST BE POSTED IN A CONSPICUOUS PLACE - NOT TRANSFERABLE i L x' OREGON HEALTH AUTHORITY Awlrno , EMERGENCY:MEDICAL SERVICES & TRAUMA SYSTEMS PROGRAM ' 47413 LICENSE NUMBER s ti 'f - - r r IFS ff f - r S,E222273 ` x• „ „ ' '80.00' PAYMENTREGENED 35 J . a d ~k EXPIRATION VIN. - -2602- °Ve, °aTE ? y X 1 tL MO DAY YR `AMBULANCE LICENSE POST IN VEHICLES3v\ 06/30/2014t l q 4 i~il E J N Yu )F h ' \ !tibJ 4City of Ashland #1501 455'Sl5kry6u Blvd r; y ADMINISTRATOR a OREGON HEALTH AUTHORITY r Ashland OR 97520 f r. a 'z r •i\~ i j:. 4 Y 1 ~t S' ~ MPS'r e A ~ , ...P r5}n. • . , • J~ ~.e ':lrt F b kuF.. ~ ` ~ 'i ^tx \~i MUST BE POSTED IN A CONSPICUOUS PLACE - NOT TRANSFERABLE c fL es- 3V w OREGON HEALTH AUTHORITY ' AUDITNO EMERGENCY:MEDICAL'SERVICE$ & TRAUMA SYSTEMS PROGRAM = t t w 47411 LICENSE NUMBER / f r{J t r r r rE211465 a ~r 80 00' PAYMENT RECEIVED EXPIRATION wN 1998S1~F`•DXE40F2XHA00469" " t ' DATE r k h f i f/y> ,{IY It MO DAY YR rx ii k ELICENSE fPOSTINVEHICLE y';r~ I1 06/30/2014 r } x aAMBULANC City of Ashland #1501 / 455-Slsklyou Blvd 'ti+$SEJ .r ''ADMINISTRATOR fr' Ashland OR 97520''J * " i OREGON HElLLTH AUTHORRY Y .r a ",r 'v 2 a 25:.. Y Ir 4'n y r ? 1. f v :y ' - x ~1 w Y. ~ _ 5 tr .p I [i5 MUST BE POSTED IN A CONSPICUOUS PLACE - NOT TRANSFERABLE r OREGON HEALTH AUTHORITY AUDIT NO EMERGENCY'MEDICAL SERVICES & TRAUMA SYSTEMS PROGRAM 474104 LICENSE NUMBERX r 1 i " ~ Y al ''r ~ / a S80 00' E198560 fr . es t" J. x ,•s' ' r T . r PAYMENTRECEIVED VIN - r / { F Cj EXPIRATION x 1996.1FDKE30F8THA48282' ~F r 't.~~. DAY MO YR 06/30/2014 AMBULANCE LICENSE POST IN VEHICLE as y , 1 ; ti 2 s City of Ashland #1501 t~ t t `E, r 455 Slsklyou BNd `:ADMINISTRATOR ' * F ( OREGON HEALTH AUTHORITY Ashland O,R 97520 t: 'i: b c Ss `4 ~I Si a 7 2 ~ ,.r ta.. MUST BE POSTED IN A CONSPICUOUS PLACE - NOT TRANSFERABLE ~f 8~• 1 r6.g3~ TNO ti OREGON HEALTH AUTHORITY + AuD147403 PUBLIC HEALTH DIVISION °EMERGENCY MEDICAL SERVICES & TRAUMA SYSTEMS PROGARM AGENCY NUMBER v-+ OPERATION DATES" 1501 t ` ~Ar ! \4 I i MO DAY YR: THRU"-MO. DAY YR y6/30/2013 ` 06/30/2014 AMBULANCE AGENCY LfCENSE POST IN AGENCY<4~ x _ _ Y ~ 4 1 r y- CIty of Ashland #1501 " r .r 455 Slskiyou Bivd '".y PAYMENT DATE ~ MO DAY YR. Ashland OR 9752Q V 05/09!2013 MUST BE POSTED IN A CONSPICUOUS PLACE - NOT TRANSFERABLE ASHLAND FIRE & RESCUE APPLICATION FOR AMBULANCE OPERATOR LICENSE 2013 Vehicles/ Equipment Level 'as of 01-01-13 VEHICLES MILEAGE TYPE LEVEL Unit # Year Model License VIN # ALS/BLS Shop # Ford 8831 2011 Lifeline E244394 IFDUF4HTOBEC53861 8381 1 ALS 845 F - 450 4X4 Ford 8833 2006 Lifeline E233465 1FDXF47F06ED06467 103,305 1 ALS 552 F-450 4X4 Ford 8832 2008 Lifeline E244368 IFDXF47R48ED90832 41,852 1 ALS 615 F-450 4X4 Ford 8834 2003 Lifeline E222273 IFDXF47F63EA10341 112,116 1 ALS 462 F - 450 4X4 Ford 8835 1999 Lifeline E211465 IFDXE40F2XHA00469 127,748 3 ALS 364 E-450 4X4 Ford 8836 1996 Lifeline E198560 1FDKE30F8THA48282 115,887 3 ALS 283 E-350 4X4 i i ® OATE (MkWD1YYYY) AC" ° CERTIFICATE OF LIABILITY INSURANCE 4/16/2012 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS i 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 pollcy(les) 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 endorsementfs . PRODUCER NAME:C Kim SchnetZky Ward Insurance Agency qHC Eat . (541) 687-1117 PAC Nc o (SSl)343-8280 P 0 Box 10167 INSURER S AFFORDING COVERAGE /UIC i I Eugene OR 97440 INSURER A:Continental Western Ins. Co. 0804 INSURED INSURERS: Ausland Builders Inc INSURER C: DBA: Ausland Group INSURERO: 3935 Highland Avenue INSURERE: Grants Pass OR 97526 INSURER F: COVERAGES CERTIFICATE NUMBER:CL1213015819 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. SR AD POLICY EFF POLICY EXP LIMITS L TYPE OF INSURANCE POLICY NUMBER MMI MOLICY GENERAL LIABILITY EACH OCCURRENCE S 1,000,000 DAMAGE 10 RhWfEU- X COMMERCIAL GENERAL LIABILITY PREMISES Ea oc n _ $ 300,000 A CLAIMSRNrDE ❑X OCCUR X 2967760 /1/2012 /1/2013 MED EXP(My one parson) $ 10,000 X $1,000 PD DED PERSONAL B ADV INAIRY $ 1,000,000 PER OCCURRENCE' GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER PRODUCTS - COMPIOP AGG $ 2,000,000 POLICY X PRO- LOC $ AUTOMOBILE LIABILITY EeemceM L 1,000,000 A X MY AUTO BODILY INJURY (Per person) $ ALL OWNED SCHEWLED 2967760 /1/2012 /1/2013 BODILY INXRY IPer-.xol.N $ ALTOS AUTOS S NON-OV.NEO PROPER YDAM X HIRED AUTOS X AUTOS Perecadonl unnsuredmaomte Nned $ X UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 5,000,0001 EXCESS LIAR E AGGREGATE $ A CWMSNIFO i DEC RETENTION 02967761 /1/2012 /1/2013 $ VYORRERS COMPENSATION NC MI5TATU- OTH- AND EMPLOYERS' LIABILITY ANY PROPRIF..TORFARTNERIENECITIVEa NIA E. I. EACH ACCIDENT S OFFICERIMEMBER E,CLUDECP (Mandatory In NH) E. L. DISEASE - FA EMPLOYE S D yYc~s, mem0e OESCRIPTgN OF F O FERATM)NS Oebw E.L. DISEASE-POLCY LIMIT S I A Limited Pollution 'WP2967760 /1/2012 /1/2013 1,000,000 i DESCRIPTION OF 0PERATIONSI LOCATIONS I VEHICLES (Aaach ACORD 101, Additional Remark. Schedule, If more apace is required) CITY OF ASHLAND, THE ARCHITECT, THEIR EMPLOYEES AND AGENTS ARE NAMED AS ADDITIONAL INSUREDS AS RESPECTS WORK PERFORMED BY NAMED INSURED UNDER WRITTEN CONTRACT AGREEMENT b PER ATTACHED CLCGO020 S CLCG2016, COVERAGE IS PRIMARY s NON-CONTRIBUTORY. WAIVER OF SUBROGATION IS APPLICABLE PER ATTACHED CLCGO020. I CERTIFICATE HOLDER CANCELLATION 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. 455 SISKIYOU BOULEVARD ASHLAND, OR 97520 AUTHORIZED REPRESENTATIVE i i Paul Jensen/CLYNN ACORD 25 (2010/05) OO 1988-2010 ACORD CORPORATION. All rights reserved. INS025(201005)01 The ACORD name and logo are registered marks of ACORD NAMED INSURED: AUSLANG BUILDERS INC DBA AUSLAND GROUP - POLICY# CVVP2967760 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. CONTRACTORS' COMMERCIAL GENERAL LIABILITY ENHANCEMENT ENDORSEMENT This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART A. MEDICAL PAYMENTS (b) That Is Fire, Lightning, Explosion or If SECTION I - COVERAGE C MEDICAL PAY- Sprinkler Leakage insurance for prem- MENTS is not otherwise excluded from this ises rented to you or temporarily occu- pied by you with the permission of the owner; 1. The Medical Expense Limit provided by this 4. Paragraph 9.a. of SECTION V - DEFINI- LIMITS subject INto the terms of shSECTION III - all be the TIONS is deleted and replaced by the follow- greater of: ing: a. $1of'. or a. A contract for a lease of premises. However, that portion of the contract for b. The Medical Expense Limit shown in the a lease of premises that indemnifies any Declarations of this Coverage Part. person or organization for damage by B. FIRE, LIGHTNING, EXPLOSION, SMOKE AND fire, lightning, explosion or sprinkler SPRINKLER LEAKAGE DAMAGE TO PREM- leakage to premises while rented to you or temporarily occupied by you with ISES YOU RENT permission of the owner is not an "in- If damage to premises rented to you under Cov- sured contract"; erage A. is not otherwise excluded from this pol- C. NON-OWNED WATERCRAFT Icy, the following applies: 1. The last paragraph of SECTION I - COV- 1. Paragraph g.(2) of SECTION I - COVER- ERAGE A.2. Exclusions is deleted and re- AGE placed A.2. Exclusions is deleted and re- placed the following: placed by the following: Exclusions c. through n. do not apply to A watercraft you do not own that is: damage by fire, lightning, explosion or sprin- (a) Less than 51 feet long; and kler leakage to premises while rented to your or temporarily occupied by you with permis- (b) Not used to carry persons or property for Sion of the owner. A separate limit of insur- a charge. ance applies to this coverage as described D. SUPPLEMENTARY PAYMENTS in SECTION III-LIMITS OF INSURANCE. SECTION I - SUPPLEMENTARY PAYMENTS 2. Paragraph 6. of SECTION III - LIMITS OF - COVERAGES A AND B is amended as fol- INSURANCE is deleted and replaced by the lows: following: 1. The limit of insurance in paragraph 1.1b. is 6. Subject to 5. above, the greater of: increased from $250 to $2,500; and a. $300,000; or 2. The limit of insurance in paragraph 1.d. is b. the Damage To Premises Rented increased from $250 to $500. To You Limit shown in the Declara- E. AUTOMATIC ADDITIONAL INSURED - tions; SPECIFIED RELATIONSHIPS Is the most we will pay under COVER- The following is added to Paragraph 2. of SEC- AGE A for damages because of "prop- TION 11- WHO IS AN INSURED: erty damage" to any one premises, while rented to you, or temporarily occupied by o. Any person or organization described in you with the permission of the owner paragraph f. below, whom you and such per- arising out of any one fire, lightning, ex- son or organization have agreed in writing in plosion orsprinkler leakage incident. a contract or agreement that such person or organization be added as an additional in- 3. Paragraph 4.b.(1)(b) Other Insurance of sured on your policy. SECTION IV - COMMERCIAL GENERAL LIABILITY CONDITIONS is deleted and re- placed by the following: CL CG 00 20 03 07 Includes copyrighted materiel of Insurance Services Page 1 of 6 Office, Inc., with its permission I i Such person or organization is an insured (c) The ownership. maintenance, or use provided: of any elevators. (1) The written or oral contract or agree- F. ADDITIONAL INSURED -OWNERS, LESSEES ment is: OR CONTRACTORS-AUTOMATIC STATUS (a) Currently in effect or becomes effec- 1. SECTION II - WHO IS AN INSURED is tive during the policy period; and amended to include as an additional insured any person or organization for whom you are (b) Executed prior to an "occurrence" or performing operations when you and such offense to which this insurance person or organization have agreed in writ- would apply. ing In a contract or agreement that such per- (2) They are not specifically designated as son or organization be added as an addi- an additional insured under any other tional insured on your policy. Such person or provision of, or endorsement added to, organization is an additional insured only this policy. with respect to liability for "bodily injury", f. Onl the followin persons or organizations "property damage" or "personal and adver- Y 9 tising Injury' caused, in whole or in part, by. are additional insureds under this endorse- ment, and coverage provided to such addi- a. Your acts or omissions; or Donal insureds is limited as provided herein: b. The acts or omissions of those acting on (1) The manager or lessor of a premise your behalf; leased to you, but only with respect to ]I- ability arising from the ownership, main- lions for the additional Insured. tenance or use of that part of the prem- ises leased to you and subject to the fol- A person's or organizations status as an ad- lowing additional exclusions: ditional insured under this policy ends when This Insurance does not apply to: your operations for that additional insured are completed. (a) Any "occurrence" which takes place after you cease to be a tenant of that 2. With respect to the insurance afforded to premises. these additional insureds, the following addi- tional exclusions apply: (b) Structural alterations, new construc- tion or demolition operations per- This insurance does not apply to: formed by or on behalf of the man- a. "Bodily injury"property damage" or ager or lessor. "personal and advertising InjIury" arising (2) Any person or organization from whom out of the rendering of, or tfre failure to . you lease equipment, but only with re- render, any professional architectural, spect to liability for "bodily Injury", "prop- engineering or surveying services, in- ertly damage" or "personal and advertis- cluding: ing injury"caused, in whole or in part, by (1) The preparing, approving, g your maintenance, operation or use of ) to prepare or approve. pnmapssihop equipment leased to you by such per- drawings, opinions, reports, surveys, Son(s) or organization(s). field orders, change orders or draw- However, this insurance does not apply ings and specifications; or to any "occurrence" which lakes place after the equipment lease expires. (2) Supervisory, inspection, architec- tural or engineering activities. (3) Any state or political subdivision, subject to the following additional provision: b. "Bodily Injury" or "property damage" This Insurance applies only with respect occurring after; to the followlnp hazards for which the (1) All work, including materials, parts slate or polltical subdivislon has Issued a or equipment furnished in connec- permit in connection with premises you tion with such work, on the project own, rent, or control and to which this in- (other than service, maintenance or surance applies: repairs) to be performed by or on existence, maintenance, reair, behalf of the additional insured(s) at (a) The construction, erection, or removal of the location n the covered opera- advertising signs, awnings, eano- lions has been completed: or pies, cellar entrances, coal holes, (2) That portion of "your work" out of driveways, manholes, marquees, which the injury or damage arises hoist away openings, sidewalk has been put to its intended use by vaults, street banners, or decora- any person or organization other tions and similar exposures; or than another contractor or subcon- The construction, erection, or re- tractor engaged in performing op- O citations for a principal as a part of moval of elevators; or the same project. I CL CG 00 20 03 07 Includes copyrighted material of Insurance Services Page 2 of 6 Office, Inc., with its permission I I 3. The insurance provided by this endorsement c. We may pay any part or all of the de- is primary insurance and we will not seek ductible amount to effect settlement of contribution under any Insurance policy un- any claim or suit and, upon notification der which such additional insured is a of the action taken; you shall promptly named insured, If such policy was procured reimburse us for such part of the de- and paid for by such additional insured, or a ductible amount as we have paid. parent or related entity of such additional in- H. BROADENED NAMED INSURED sured. 4. With respect to the insurance afforded to Paragraph 3. of SECTION II - WHO IS AN IN- these additional insureds, SECTION III - SURED is deleted and replaced by the following: LIMITS OF INSURANCE is amended as fol- Any organization, other than a joint venture, over lows: which you maintain ownership or majority inter- The limits applicable to the additional in- est of more than 50% will be a Named Insured if specified in the written con- there is no other similar insurance available to shred are those tract or agreement or the limits slated in the that organization. However: Declarations, whichever is less. If no limits a. Coverage under this provision is afforded are specified in the written contract or only until the 180th day after you acquire or agreement, the limits applicable to the addi- form the organization or the end of the policy tional insured are those specified in the Dec- period, whichever is earlier. larations. The limits of insurance are inciu- b. COVERAGE A does not apply to "bodily in- sive of and not in addition to the limits of in- jury" or "property damage" that occurred be- surance shown in the Declarations. fore you acquired or formed the organiza- G. PROPERTY DAMAGE TO BORROWED tion. EQUIPMENT c. COVERAGE B does not apply to "personal 1. Paragraph 2.j. of SECTION 1 - COVER- and advertising injury" arising out of an of- AGES, COVERAGE A BODILY INJURY fense committed before you acquired or AND PROPERTY DAMAGE LIABILITY is formed the organization. amended as follows: I. CONSTRUCTION PROJECT GENERAL AG- Paragraphs (3) and (4) of this exclusion do GREGATE LIMIT not apply to tools or equipment loaned to 1. For all sums which the insured becomes you, provided they are not being used to per- legally obligated to pay as damages caused form operations at the time of loss. by "occurrences" under COVERAGE A 2. SECTION III - LIMITS OF INSURANCE Is (SECTION 1), and for all medical expenses deleted and replaced by the following: caused by accidents under COVERAGE C (SECTION 1), which can be attributed only to The most we will pay In any one "occur- ongoing operations at a single construction rence" for "property damage" to borrowed project away from premises owned by or equipment is $15,000. This limit of incur- rented to the insured: ante Is the most we will pay regardless of a. A Single Construction Project General the number of: Aggregate Limit applies to each con- a. Insureds; struction project away from premises and b. Claims made or "suits" brought; or that limit Is equal otthe amount of the owned by or rented e c. Persons or organizations making claims General Aggregate Limit shown in the j or bringing "suits". Declarations. 3. Deductible b. The Single Construction Project General Aggregate Limit is the most we will pay a. Our obligation to pay damages on behalf for the sum Of all damages under COV- of the insured applies only to the amount ERAGE A, except damages because of of damages in excess of $250 as appli- "bodily injury' or 'property damage" in- cable to "properly damage" as the result eluded in the 'Products-completed op- of any one "occurrence", regardless of erations hazard', and for medical ex- the number of persons or organizations penses under COVERAGE C regardless who sustain damages because of that of the number of: occurrence". b. The terms of this insurance, Including (1) Insureds; those with respect to our right and duty (2) Claims made or "suns" brought; or to defend the insured against any "suits" (3) Persons or organizations making seeking those damages; and your duties claims or bringing "suits". in the event of an "occurrence', claim, or "suit" apply Irrespective of the application of the deductible amount. i CL CG 00 20 03 07 Includes copyrighted material of Insurance Services Page 3 of 6 Office, Inc., with its permission I I c. Any payments made under COVERAGE J. KNOWLEDGE OF OCCURRENCE A for damages or under COVERAGE C The following is added to paragraph 2. Duties In for medical expenses shall reduce the The Event Of Occurrence, Offense, Claim Or I Single Construction Project General Ag- Suit of SECTION IV - COMMERCIAL GEN- gregate Limit for that construction pro- ERAL LIABILITY CONDITIONS- . ject away from premises owned by or - rented to the Insured. Such payments e. A report of an "occurrence", offense, claim shall not reduce the General Aggregate or "suit" to: Limit shown in the Declarations nor shall (1) You, if you are an individual, they reduce any other Single Construc- tion Project General Aggregate Limit for (2) A partner, if you are a partnership, any other separate construction project away from premises owned by or rented (3) An executive officer, if you are a to the insured. corporation, or d. The limits shown in the Declarations for (4) A manager, if you are a limited liability Each Occurrence, Fire Damage and company, Medical Expense continue to apply. is considered knowledge and requires you to However, instead of being subject to the notify us of the "occurrence", offense, claim, General Aggregate Limit shown in the or "suit" as soon as practicable. Declarations, such limits will be subject to the applicable Single Construction f. We are considered on notice of an Project General Aggregate Limit. occurrence", offense, claim or "suit" that is . For all sums which the Insured becomes reported to your Workers' Compensation 2legally obligated h dame caused insurer for an event which later develops into pay as damages an "occurrence", offense, claim or "suit" for by "occurrences" under COVERAGE A which there is coverage under this policy. (SECTION 1), and for all medical expenses However, we will only be considered on caused by accidents under COVERAGE C notice if you notify us as soon as you know (SECTION 1), which cannot be attributed the claim should be addressed by this policy only to ongoing operations at a single deslg- rather than your Workers' Compensation nated construction project away from prem- parley. ises owned by or rented to the insured: a. Any payments made under COVERAGE K. UNINTENTIONAL OMISSIONS A for damages or under COVERAGE C The following is added to paragraph 6. Repre- for medical expenses shall reduce the sentations of SECTION IV - COMMERCIAL amount available under the General Ag- GENERAL LIABILITY CONDITIONS: gregate Limit or the Products-Completed d• if you unintentionally fail to disclose any ex- Operations Aggregate Limit, whichever posures existing at the Inception date of your Is applicable; and policy, we will not deny coverage under this b. Such payments shall not reduce any Coverage Part solely because of such failure Single Construction Project General Ag- to disclose. However, this provision does ! gregate Limit. not affect our right to collect additional pre- 3. When coverage for liability arising out of the mium or exercise our right of cancellation or non-renewal, "products-completed operations hazard" Is I provided, any payments for damages be- This provision does not apply to any known cause of *bodily injury' or "property damage" injury or damage which is excluded under included in the "products-completed opera- any other provision of this policy. lions hazard" will reduce the Products- L. MENTALANGUISH Completed Operations Aggregate Limit, and Paragraph 3. of SECTION V -DEFINITIONS is not reduce the General Aggregate Limit nor the Single Construction Project General Ag- deleted and replaced by the following: gregate Limit. 3. "Bodily injury" means bodily injury, sickness 4. If the applicable construction project away or disease sustained by a person, including from premises owned by or rented to the in- mental anguish or death resulting from any sured has been abandoned, delayed, or of these at anytime. abandoned and then restarted, or if the au- M. WAIVER OF TRANSFER OF RIGHTS OF RE- thorized contracting parties deviate from COVERY AGAINST OTHERS plans, blueprints, designs, specifications or Paragraph 8. Transfer Of Rights Of timetables, the project will still be deemed to Recovery be the same construction project. Against Others To Us of SECTION IV - COM- MERCIAL GENERAL LIABILITY CONDITIONS 5. The provisions of Limits Of Insurance is amended by the addition of the following: (SECTION III) not otherwise modified by this endorsement shall continue to apply as stipulated. CL CG 00 20 03 07 Indudas copyrighted material of Insurance Servloazi Page 4 of 6 Office, Inc., with its pennixsion i I I We waive any right of recovery we may have be- the premises, site or loca- cause of payments we make for injury or dam- tion in connection with such age arising out of your ongoing operations or operations by such insured, your work" done under a contract requiring such contractor or subcontractor. - waiver with that person or organization and in- cluded in the "products-completed operations Subparagraph (b) does not hazard". apply to bodily injury' or "property damage" arising However, our rl~hts may only be waived prior to out of heat, smoke or fumes the "occurrence giving rise to the injury or dam- from a "hostile fire". age for which we make payment under this Cov- erage Part. The insured must do nothing after a (2) Any loss, cost or expense aris- loss to impair our rights. At our request, the in- ing out of any. sured will bring "suit" or transfer those rights to (a) Request, demand, order or us and help us enforce those rights. statutory or regulatory re- N. LIMITED JOB SITE POLLUTION quirement issued or made 1. Exclusion f. under Section I - Covera e A pursuant to any environ- 9 mental protection or envi- is replaced by the following ronmental liability statutes or 2. Exclusions regulations that any insured lest for, monitor, clean up, This insurance does not apply to: remove, contain, treat, de- f, Pollution toxify or neutralize, or in any way respond to, or assess (1) "Bodily injury" or "property dam- the effects of, "pollutants"; age" arising out of the actual, al- or leged or threatened discharge, {b) Claim or suit by or on behalf dispersal, seepage, migration, of a governmental authority release or escape of "pollut- for damages because of ants": testing for, monitoring, (a) At or from any premises, cleaning up, removing, con- site or location on which any talning, treating, detoxifying insured or any contractors or neutralizing or in any way or subcontractors working responding to or assessing directly or indirectly on any the effects of, "pollutants". Insured's behalf are per- forming operations if the However, this paragraph does operations are to test for, not apply to liability for those itor, clean up, remove, sums the insured becomes le- monconito , treat, detoxify e, gally obligated to pay as dam- neutralize, or in any way re- ages because of "properly dam- spond to, or assess the ef- age" that the Insured would fects of, "pollutants"; or have In the absence of such re- quest, demand, order or stalu- (b) At or from a storage tank or tory or regulatory requirement, other container, ducts or or such claim or "suit" by or on piping which is below or par- behalf of a governmental author- . tially below the surface of ity, the ground or water or 2. With respect to "bodily injury' or " roperty which, at any time, has been damage" arising out of the actual, alleged or buried under the surface threatened discharge, dispersal, seepage, the ground or water and d then subsequently exposed migration, release or escape of "pollutants": by erosion, excavation or a. The "Each Occurrence Limit" shown in any other means if the ac- the Declarations does not apply. dual, alleged or threatened discharge, dispersal, soap- b, Paragraph 7. of Limits Of Insurance I age, migration, 'release or (Section III) does not apply. escape of "pollutants" arises c. Paragraph 1. of Section III - Limits Of at or from any premises, site Insurance is replaced by the following: or location which any in- sured or any contractors or The Limits Of Insurance shown in this subcontractors working di- endorsement, or in the Declarations and rectly or indirectly on any in- the rules below fix the most we will pay sured's behalf are perform- regardless of the number of: ing operations If the "pollut- ants" are brought on or to i CL CG 00 20 03 07 Includes copyrighted materiel of Insurance Services Page 5 of 6 Of(co, Inc., with its pormission I I I (2) Claims made or "suits" brought; or 9. Subject to 8. above, the Medical Expense Limit is the most we will (3) Persons or organizations making pay under Coverage C for all medi- claims or bringing "suits". cal expenses because of "bodily in- d. The following are added to Section III - jury' sustained by any one person Limits Of Insurance: arising out of the actual, alleged or threatened discharge, dispersal, 8. Subject to 2. or 3. above, whichever - seepage, migration, release or es- applies, the most we will pay for the cape of "pollutants". sum of: 0. OTHERINSURANCE a. Damages under Coverage A; and If this policy includes a Coverage Form or an Endorsement which pprovides coverage for loss b. Medical expenses under Cover- or damage covered by one or more of the Ex- age C tensions of this endorsement, the limit and the j because of "bodily injury" or "prop- coverage provided by this endorsement are de- - damage" arising out of the ac- leted and replaced by the limit and coverage tual, alleged or threatened dis- provided by that Coverage Form or Endorse- - charge, dispersal, seepage, m(gra- ment. lion, release or escape of "pollut- ants" is $100,000. j i i i i I CL CG 00 20 03 07 Includes copyrighted material or insurance services Page 6 of 6 Office, Inc., with its permission ReferenceConnect Page I of I j CWG I General Liability 101101107 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. I CL CG 20 16 01 07 OREGON ADDITIONAL INSURED - OWNERS, LESSEES OR CONTRACTORS - COMPLETED OPERATIONS - AUTOMATIC STATUS WHEN REQUIRED BY WRITTEN CONTRACT This endorsement modifies Insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART Section II - Who Is An Insured is amended to include as an additional insured any person or organization for whom you are performing operations when you and such person or organization have agreed in writing in a contract or agreement that such person or organization be added as an additional insured on your policy. Such person or organization is an additional insured only to the extent that the liability for "bodily Injury" or "property damage" is caused by "your work" performed for that additional insured at locations, specified in the written contract or agreement and included in the "products-completed operations hazard". I With respect to the insurance afforded to these additional insureds, this insurance does not apply to "bodily injury" or "property damage" that occurs prior to the execution of, or subsequent to the expiration of, the contract or agreement in which you agreed that such person or organization be added as an additional insured on your policy. i . I I OContinental Western Group 02012 Vertafore, Inc. All Rights Reserved i I i i i I i I I i https://wwwv.silverplume.conVsponline/SPSAGE.ASP?cnid=doc&id=cwi47543&fed=14100... 1/9/2012