HomeMy WebLinkAboutInsurance Certificate: Noble Coffee Roasting
9NOBLCO OP ID: SL
CERTIFICATE OF LIABILITY INSURANCE 022/26/ °A12612014
014
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 endorsement(s).
PRODUCER, Phone: 541-779-4232 a NT ACT
He Ifl6Urance • _ NAME:
1123 Royal Ave. - - Fax: 541-7723963 PHONE - - FAX' -
Medford, OR 97604 E-Ma~ A/c No :
Hart Insurance Agency - - ADDRESS: - .
INSURER(S) INSURERA:AmericINSURED Noble Coffee Roasting LLC INsuRERe:SAIF Cdba Noble Coffee Roasting
261 Fourth Street ' INSURER C:
Ashland, OR 97520' SISURERD:
INSURERS:
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
LT TYPE OF INSURANCE AUDI 3usf POLICY NUMBER IIDDIYYYY) M UCY EFF MID Y EXP UMRS
GENERAL LIABILITY
11 EACH OCCURRENCE S 1,000,00
A X COMMERCIAL GENERAL LIABILITY X 44PB463762 04113/2014 04/1312015 PR ISES Eaom,oenoe S 1110,00
CLAIMS4MADE OCCUR MEDEXP (Airy oneiomcn) $ 5,011
PERSONAL S ADV INJURY E 1,000,00
_ GENERAL AGGREGATE S 2,000,00
'GENT AGGREGATE LIMIT APPLIES PER PRODUCTS-COMP/OP AGO S- - _ 2,000,00
PRO- -1
XDED'L Y LOC LE LIABILITY ..IeMBHEM ANGLE LIMB
UTO - BODILY INJURY(Par person) S NED SCHEDULED
AUTOS BODILY INJURY (Per accuem $ NON OWNED )
AUTOS AUTOS PRmOP~ERpAMA E $
LLA LUIS EACH OCCURRENCE S
S LIAM AGGREGATE $
RETENTIONS
WORKERS COMPENSATION $
AND EMPLOYERS' LABILITY WC STATU- OTH-
B ANY PROPRIETORIPARTNER/EXECUINE VIN 776066 01101/2014 01/111/2015 is 500,00
OFFICERIMEMBER EXCLUDED? ❑ NIA EL. EACH ACCIDENT
(Mandatory In NH)
tiyas, do -'m uMer E.L. DISEASE - EA EMPLOYEE f 5110,011
DESCRIPnroN OF OPERATIONS below -
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ANadh ACORD 101, Additional Remarks Schedule, H mom apeee's requlnd)
Certificate holder is additional insured per attached CBP045
CERTIFICATE HOLDER CANCELLATION
CITYASH
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
City of Ashland i ACCORDANCE WITH THE POLICY PROVISIONS.
20 E. Main Street
Ashland, OR 97520 AUTHORRED REPRESENTATIVE
Hart Insurance Agency
®1988.2010 ACO ORPORATION. All rights reserved.
ACORD 25 (2010/05) The ACORD name and logo are registered marks of ACORD
POLICY NUMBER: COMMERCIAL ADVANTAGE POLICY
CBP 045 03 05
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
ADDITIONAL INSURED - DESIGNATED PERSON
OR ORGANIZATION
This endorsement modifies insurance provided under the following:
COMMERCIAL ADVANTAGE POLICY
SCHEDULE
Name Of Additional Insured Person(s) Or Organization(s):
Information required to complete this Schedule, if not shown on this endorsement, will be shown in the Declara-
tions.
The following is added to Paragraph C. Who Is An Insured in Section II - Liability :
4. Any person(s) or organization(s) shown in the Schedule is also an additional insured, but only with respect to
liability for "bodily injury," "property damage" or "personal and advertising injury" caused, in whole or in part, by
your acts or omissions or the acts or omissions of those acting on your behalf in the performance of your ongo-
ing operations or in connection with your premises owned by or rented to you.
CBP 045 03 05 Includes copyrighted material of Insurance Services Office., Inc., Page 7 of 1 ❑
with its permission