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HomeMy WebLinkAboutInsurance Certificate: Childrens Dental Clinic A`~ CERTIFICATE OF LIABILITY INSURANCE 1/23/2014 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(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 endorsement(s). PRODUCER CONTACT Jdnese Larsen, AAI, CPIW NAME: AIC Pacific Benefit Consultants PHONE . (541) 484-6624 FAXNo,. (541) 686-2726 450 Country Club Road #330 E'MaL jlarsen@pbcins. com INSURER(S) AFFORDING COVERAGE NAIC9 Eugene OR 97401 INSURERA:Sentinel Insurance Company 11000 INSURED INSURER s:Chubb Insurance CHILDRENS DENTAL CLINC OF JACKSON CO INSURER C: 229 W STEWART AVE INSURER D: INSURER E : MEDFORD OR 97501 INSURER F: COVERAGES CERTIFICATE NUMBER:2013-14 Certs 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 DLS POLICY NUMBER MM D POLICY IYYEFF YY MODDY EXP Jan J= LTR UNITS GENERAL UABarY EACH OCCURRENCE E 1,000,000 X COMMERCIAL GENERAL LIABILITY DAMAGE T PREMISES Ea occunence E 1,000,000 A CLAIMS-MADE MOCCUR X 2SBAF00588 2/23/2013 2/23/2014 MED EXP( one pereon) f 10,000 PERSONAL 8 ADV INJURY E 1,000,000 GENERAL AGGREGATE E 2,000,000 GENL AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMPIOP AGG E 2,000,000 X POLICY PRO LOC E AUTOMOBILE UABILITY COMBINED SINGLE LIMIT (Ea acrideM BODILY INJURY (Par person) E ANY AUTO ALL OY.MED SCHEDULED BODILY INJURY (PermuxlenO f AUTOS NAUTOS ON-OMED PROPERTY DAMAGE S HIRED AUTOS AUTOS Per accken E UMBRELLA Me OCCUR EACH OCCURRENCE f EXCESS UAB CLAIMS-MADE AGGREGATE E DEC) RETENTION$ E WORKERS COMPENSATION VIC STATU- OTH- ANDEMPLOYERS'UABIUTY YIN ANY PROPRIETORIPARTNERlEXECUTVEā¯‘ NIA E.L. EACH ACCIDENT E OFFICERIMEMBER EXCLUDED? IMardatory In NB) E.L. DISEASE -EA EMPLOYE f 8yes, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE -POLICY LIMB E B Directors 6 Officers 1689247 /1/2014 /1/2015 $50D0[)0 Mmm,wn lend of DESCMPTON OF OPERAnONS I LOCATIONS I VEHICLES (Attach ACORD 181, Additional Remarks Schedule, U more apace Is required) 30 days notice of cancellation , Except 10 days notice in event cancellation for non payment of premium The City of Ashland, its officers, employees, and agents are included as additional insured as respects to general liability operations usual to the named insured. CERTIFICATE HOLDER CANCELLATION (541) 552-2059 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. Attn: Kristy Blackman 20 East Main Street AUTHORIZED REPRESENTATIVE Ashland, OR 97520 J Larsen, AAI, CPiW/J ACORD 25 (2010/05) ©1988-2010 ACORD CORPORATION. All rights reserved. INS025 (2moo5).01 The ACORD name and logo are registered marks of ACORD