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HomeMy WebLinkAboutInsurance Certificate: American Industrial Door LLC AMERIND-03 PHITE DIYYYY) ,acoRO CERTIFICATE OF LIABILITY INSURANCE 9/11118/2 DA 812013 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 INS_ URE_ R(S), AUTHORIZED -REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. - - IMPORTANT:-If.the, certificate holder is an ADDITIONAL INSURED, the policy(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 certificateidoes,not confer rights 4o the" certificate.holderin'lleu of such endorsement(s).! = CONTACT 'PRODUCER. . _ , NAME:' i ' - . Medford Office PHONE' (541) 779-1321 1412.1 `.1a' ac Ne: (541) 779-9187 PayneWest Insurance, Inc. - - Iuc No Eat 38 North Central Ave. f-, E-MAIL RESS: Suite 100 - Medford, OR 97501 INSURER(S) AFFORDING COVERAGE NAIC0 INSURER A: Western National Mutual INSURED INSURER B: Western National Assurance Cc 24465 American Industrial Door LLC; American Industrial Door CO. INSURER C: 5022 Table Rock Rd. INSURER D: Central Point, OR 97502 INSURER E: INSURER F: I 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. INBR TYPE OF INSURANCE POLICY NUMBER MMLDDY L 1= J= IYYVY MM/DDYl1MR LIMITS R GENERAL LIABILITY EACH OCCURRENCE E 1,000,00 A X COMMERCIAL GENERAL LIABILITY X CPPI059502 6123/2013 612312014 PREMISES E. occunenca E 100,00 CLAIMS-MADE OCCUR MED E%P (Arty one person) E 5,000 PERSONAL 8 ADV INJURY E 1,000,00 _,_-t° "•r) 'I GENERAL AGGREGATE 8-+/ 2,000,00 PRODUCTS - COMPIOP AGG 8 2,000,00 ".GEN rAGGREGATE LIMIT, APPLIES PER'-------•-•---••-----.__._. -r ' f: ..POLICY, :X, .PRO r, .L OD - 8 i COMBINED SINGLE LIMIT" ^ :.'l AUTOMOBILE LIABILITY E '000,00 ANY AUTO X ••CPP.1058471-01 _ 6123/2013-6/23/2014- BODILY INJOkY(Perperson). S ALL OWNED !SC HEDULED BODILY INJURY (Per acddenn E , UTOS X H R DSAUr05 X NON-OWNED'• - - - PROPERTY DAMAGE 8 " AUTOS Peraccidenl X UMBRELLA LIAB X OCCUR EACH OCCURRENCE S 2,000,00 A EXCESS LIAB CLAIMS-MADE UMB1009693-01 612312013 6/2312014 AGGREGATE E 2,000,00 DED X RETENTIONS 10,000 8 WORKERS COMPENSATION - WC STATUS OTH- ANDEMPLOYERS' LIABNTY YIN T RV IMIT ER ECUTIVE❑ IA E.L. EACH ACCIDENT E OFFICERiMEMER EXCLUDED? N (Mandatory In NH) E.L. DISEASE- EA EMPLOYE E If yes, describe under E.L. DISEASE-POLICY LIMIT 8 DESCRIPTION OF OPERATIONS W. DESCRIPTION OF OPERATIONS / LOCATIONS I VEHICLES (ANach ACORD 101, AdditionsI Remarks Schedule, if more space Is required) RE: 2013 Slurry Seal Project #2013-10 The City of Ashland, OR and its elected officials, officers and employees are additional insureds when required by written contract but only with respect to insured services to be provided to them under this contract as per attached forms - GL #WNGL52 (01109). Coverage Is Primary and non-contributory. Auto form #WNCA37 (11/12). 30 day Cancellation notice on GL except 10 days for non-payment of premium, form #WNGL69 (12110) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE City of Ashland THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Y 20 E. Main SL ACCORDANCE WITH THE POLICY PROVISIONS. Ashland, OR 97520 AUTHORIZED REPRESENTATIVE x 4i, ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25 (2010/05) The ACORD name and logo are registered marks of ACORD COMMERCIAL GENERAL LIABILITY WN GL 52 01 09 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. OREGON ADDITIONAL INSURED - OWNERS, LESSEES OR CONTRACTORS -AUTOMATIC STATUS WHEN REQUIRED IN CONSTRUCTION AGREEMENT WITH YOU PRIMARY AND NONCONTRIBUTORY This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART A. Section II - Who Is An Insured is amended to a. The preparing, approving, or failing to pre- include as an additional insured any person or or- pare or approve, maps, shop drawings, ganization for whom you are performing operations opinions, reports, surveys, field orders, when you and such person or organization have change orders or drawings and specifica- agreed in writing in a contract or agreement that tions; or such person or organization be added as an addi- tional insured on your policy. Such person or or- b. Supervisory, inspection, architectural or ganization is an additional Insured only with respect engineering activities. to liability for "bodily injury", "property damage" or 2. "Bodily injury" "personal and advertising injury" caused by your 1 rY" or "property damage" occurring after: ongoing operations for the additional insured and only to the extent that such "bodily injury", "property a. All work, including materials, parts or equip- damage" or "personal and advertising injury" is ment furnished in connection with such caused by your negligence or the negligence of work, on the project (other than service, those performing operations on your behalf. maintenance or repairs) to be performed by A person's or organization's status as an additional or on behalf of the additional insured(s) at the location of the covered operations has insured under this endorsement ends when your been completed; or operations for that additional insured are com- pleted. b. That portion of "your work" out of which the injury or damage arises has been put to its B. The Limits of Insurance applicable to the additional intended use by any person or organization insured are those specified in the written contract other than another contractor or subcontrac- or written agreement or in the Declarations of this for engaged in performing operations for a policy, whichever is less. These Limits of Insur- principal as a part of the same project. ance are inclusive of, and not in addition to Limits of Insurance shown in the Declarations. D. As respects the coverage provided under this en- dorsement, Paragraph 4.b. of the Other Insurance C. With respect to the insurance afforded to these Condition is deleted and replaced by the following: additional insureds, the following additional exclu- sions apply: 4. Other Insurance This insurance does not apply to: b. Excess Insurance 1. "Bodily injury", "property damage" or "personal This insurance is excess over any other and advertising injury" arising out of the render- insurance naming the additional insured as ing of, or the failure to render, any professional an insured whether primary, excess, contin- architectural, engineering or surveying services, gent or on any other basis unless the written including: contract or agreement described in A. above specifically requires that this insurance be provided on either a primary basis or a pri- mary and noncontributory basis. WN GL 52 01 09 Includes copyrighted material of Insurance Sendoes Office Inc. with its permission. Page 1 of 1 ❑ WN CA 27 11 12 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY BUSINESS AUTO ENHANCEMENT ENDORSEMENT This endorsement modifies the insurance provided under the following: BUSINESS AUTO COVERAGE FORM With respect to the coverage provided by this endorsement, the provisions of the Coverage Form apply unless modified by this endorsement. The SECTIONS of the Business Auto Coverage Form identified in this endorsement will be amended as shown below. SECTION It - LIABILITY COVERAGE f. Any "employee" of yours is an "insured" while AMENDMENTS using a covered "auto" you don't own, hire or borrow in your business or your personal A. Who Is An Insured -amended affairs. SECTION II - LIABILITY COVERAGE, Item A. g, Any "employee" of yours is an "insured" while Coverage, 1. Who Is An Insured is amended to operating a covered "auto" hired or rented add: under a contract or agreement in the d. Any legally incorporated subsidiary of yours in "employee's" name, with your permission, which you own more than 50% of the voting while performing duties related to the conduct stock on the effective date of this coverage of your business. form. B. Blanket Additional Insured However, "insured" does not include any Section II - LIABILITY COVERAGE, Item A. subsidiary of yours that is an "insured" under Coverage, 1. Who Is An Insured, paragraph c. any other automobile liability policy, or would is amended to add the following: be an "insured" under such policy but for termination of such policy or the exhaustion Any person or organization who is required under on such policy's limits of insurance. a written contract or agreement between you and that person or organization, that is signed and e. Any organization which is newly acquired or executed by you before the "bodily injury" or formed by you and over which you maintain "property damage" occurs and that is in effect majority ownership. However, coverage during the policy period, to be named as an under this provision: additional insured is an "insured" for Liability (1) is afforded only for the first 180 days after Coverage, but only for damages to which this you acquire or form the organization or insurance applies and only to the extent that until the end of the policy period, persons or organization qualifies as an "insured" whichever comes first; under the Who Is An insured provision contained in Section Il. (2) does not apply to "bodily injury" or "property damage" that results from an C. Liability Coverage Extensions - 'accident" that occurred before you Supplementary Payments formed or acquired the organization; SECTION 11 - LIABILITY COVERAGE, Item A. (3) does not apply to any newly acquired or Coverage, 2. Coverage Extensions, a. formed organization that is a joint venture Supplementary Payments is amended by or partnership; and replacing subparagraphs (2) and (4) with the following: (4) does not apply to an "insured" under any other automobile liability policy, or would (2) Up to $5,000 for cost of bail bonds (including be an "insured" under such a policy but bonds for related traffic law violations)required for termination of such policy or the because of an "accident" we cover. We do exhaustion of such policy's limits of not have to furnish these bonds. insurance. (4) All reasonable expenses incurred by the WN CA 27 11 12 Includes copyrighted material of Insurance Services Office, with its permission Page 2 of 5 DST oooe21N COMMERCIAL GENERAL LIABILITY WN GL 6912 10 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. NOTICE OF CANCELLATION ENDORSEMENT This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART The following condition is added: If we cancel this policy, for any reason other than nonpayment of premium, we will mail advance notice to the person(s) or organization(s) as shown in the Schedule in accordance with the Cancellation and Nonrenewal conditions of the policy and any applicable endorsements. SCHEDULE Person or Organization (Name and Address) 30 day cancellation notice City of Ashland 20 E. Main St. Ashland, OR 97520 WN GL 69 12 10 Page t of 1