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OREGON WORKERS COMPENSATION Sai f
CERTIFICATE OF INSURANCE Jcorporation
CERTIFICATE HOLDER:
CITY OF ASHLAND
20 EAST MAIN ST.
ASHLAND, OR 97520
The policy of insurance listed below has been issued to the insured named below for the
policy period indicated. The insurance afforded by the policy described herein is subject to
all the terms, exclusions and conditions of such policy.
POLICY NO. POLICY PERIOD ISSUE DATE
812919 10/01/2013 to 10/01/2014 10/30/2013
INSURED: BROKER OF RECORD:
PACIFIC PAVING INC KPD INSURANCE INC
PACIFIC POWDER COATING PO BOX 29
PO BOX 2370 SPRINGFIELD, OR 97477
WHITE CITY, OR 97503-0370
LIMITS OF LIABILITY:
Bodily Injury by Accident $500,000 each accident
Bodily Injury by Disease $500,000 each employee
Body Injury by Disease $500,000 policy limit
DESCRIPTION OF OPERATIONS/LOCATIONS/SPECIAL ITEMS:
IMPORTANT:
The coverage described above is in effect as of the issue date of this certificate. It is subject to change
at any time in the future.
This certificate is issued as a matter of information only and confers no rights to the certificate holder.
This certificate does not amend, extend or alter the coverage afforded by the policies above. This
certificate does not constitute a contract between the issuing insurer, authorized representative or
producer and the certificate holder.
AUTHORIZED REPRESENTATIVE
President and CEO
400 High Street SE
Salem. OR 97312
P: 800.285.8525
F: 503.373.8020
Policy_eatch_CertlocateOfInsumnce