HomeMy WebLinkAboutInsurance Certificate: Pacific Paving
CITY RECO ,EER PACIOSC OP ID: LCH
D 3/2 5120 1 4Y)
CERTIFICATE OF LIABILITY INSURANCE 03/2512014
0
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 endorsemen s .
PRODUCER Phone: 541-245-1111 NAMEACT Therese Rayburn
United Risk Solutions, Inc. Fax: 541-245-1112 PHONE 541-245-1111 (FN"
PO Box 936 A.14. r+g€N' INC. Not: 541'245'1112
Medford, OR 97501.0067 ADDRESS: therese.raybum@unitedrisk.com
INSURERS AFFORDING COVERAGE NAIL N
INSURER A ; Western NaOonal Ins Group \
INSURED Pacific Paving, Inc INSURER B:
PO Box 2370
White City, OR 97503 INSURER C
INSURER D
INSURER E:
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 TYPE OF INSURANCE ADDL SUER POLICY NUMBER MMIDDYYYY MMLIDYYYY LIMITS
LTR
GENERAL LIABILITY EACH OCCURRENCE $ 1,000,06
A X COMMERCIALGENERAL LIABILITY X CPP107021801 0312012014 0312012015 PREMISES Ea occurrence $ 100,000
IX I OCCUR MED EXP(Myone Pelson) $ 5,06
CLAIMS-MADE
PERSONAL B ADV INJURY $ 1,000,06
GENERAL AGGREGATE $ 2,000,06
GENL AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG E 2,000,000
X' POLICYI PRP LOG $
AUTOMOBILE LIABILITY COMBINED SINGLE OMIT 1,666,66
Ea aaident
A ANYAUTO CPP106912801 0312012014 0312012015 BODILY INJURY (Per person) $
X ALLOWNED SCHEDULED BODILY INJURY (Per accident) $
AUTOS AUTOS
X HIRED AUTOS X 'or-0WNED PROPERTY DAMAGE $
AUTOS Per accident
UMBRELLA LIAR OCCUR EACH OCCURRENCE $
EXCESS LIAB CLAIMS-MADE AGGREGATE $
DED RETENTIONS $
WORKERS COMPENSATION TORY LIMITS ER
AND EMPLOYERS' LIABILITY YIN
ANY PROPRIETORPARTNEREYFCUT11E EL. EACH ACCIDENT $
OFFICEWMEMBER EXCLUDED? NIA
(Mandatory in NH) E. L. DISEASE-EA EMPLOYE $
If fts 0 under
DESCRIPTION OFOPERATIONS W. E. L. DISEASE-POLICY LIMIT $
DESCRIPTION OF OPERATIONS I LOCATIONSI VEHICLES (Attach ACORD 101, Addldonal Remarks Schedule, H more space la required)
City of Ashland is hereby named as additional insured per form
WNGL39 (03/10)
CERTIFICATE HOLDER CANCELLATION
CITAS01
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
of Ashland THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
City ACCORDANCE WITH THE POLICY PROVISIONS.
Karl Olson Purchasing Rep
90 N. Mountain Ave. AUTHORIZED REPRESENTATIVE
Ashland, OR 97520-2014
01988-2010 ACORD CORPORATION. All rights reserved.
ACORD 25 (2010105) The ACORD name and logo are registered marks of ACORD