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HomeMy WebLinkAboutInsurance Certificate: Western Burner I ea Hau CERTIFICATE OF LIABILITY INSURANCE °"3/24 01°4YYY) THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERT'IFICATE'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 pollcy(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 NAME: Susan Rendsland Commercial Lines - (541) 685-5300 PHONE FAX WC. Me 9n0. 541-685-5343 ac Ne 866-968-4807 Wells Fargo Insurance Services USA, Inc. E-MAIL ADDRESS: Susan.rendslandGwellsfar9o.cem 975 Oak Street, Suite 900 _ INSURER(S) AFFORDING COVERAGE NAIL S Eugene, OR 97401 INSURER A: Houston Specialty Insurance Company 12936 INSURED INSURER B: Ohio Security Insurance Company 24082 Western Burner Company INSURER f 5851 Peace Lane INSURER D INSURER E : Central Pohl, OR 97502 INSURER F: COVERAGES CERTIFICATE NUMBER: 7478744 REVISION NUMBER: See below 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 INAOC SO SUER POLICY NUMBER MYIDCD~ POLICY Y Y LIMITS LTR X COMMERCIALGENERKLIABILRY 100.000 A TEN-13822 3124/2014 312412015 DAMAGE TOR ENTE f CLAIMS-MADE FxIOCCUR -PREMISES EEa ED 50000 occurrence $ X $1,000 DeduOIN. MED EXP(Any one person) f 5,000 X Per Occurrence PERSONAL f ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 X POLICY I~ PRO LOG PRODUCTS - COMP/OP AGG $ 2,000,000 JECT OTHER: f B AUTOMOBILE LIABILITY BAS1555002181 3124/2014 3124/2015 COMBINED SINGLE.. LIMIT $ 1,000,000 _(Ea acelda _ ANY AUTO BODILY INJURY (Per person) $ ALL OWNED X SCHEDULED BODILY INJURY (Per axident) $ AUTOS AUTOS X X NON-OWNED PROPERTY DAMAGE f HIRED AUTOS AUTOS Per aecId M f UMBRELLA I" OCCUR EACH OCCURRENCE S EXCESS LIAR CIAIMS-MADE AGGREGATE If DED RETENTIONS $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS' LIABILITY YIN STATUTE ER ANY PROPRIETORIPARTNER/EXECUTIVE ❑ E.L. EACH ACCIDENT S OFFICER/MEMBER EXCLUDED? NIA (Mandalor In NN) E.L. DISEASE - EA EMPLOYEE f Ayes. descrift under DESCRIPTION OF OPERATIONS aglow E.L. DISEASE - POLICY LIMIT S DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarta Schedule, may a aeachad If mom apace Is required) Certificate Holder is an Additional Insured under General Liability per Form CG 2037 07/04 attached. CERTIFICATE HOLDER CANCELLATION City of Ashland SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE 20 East Main Street THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Ashland, OR 97520 AUTHORMED REPRESENTATIVE The ACORD name and logo are registered marks of ACORD © 1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25 (2014101) 111111111111111111111111111111111 IN 11111111111111111111111111111111111111111111111111111 •LYeppA'GrgpN,g03AllmeeN• POLICY NUMBER: TEN-13822 COMMERCIAL GENERAL LIABILITY CG 20 37 07 04 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - OWNERS, LESSEES OR CONTRACTORS - COMPLETED OPERATIONS This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Name Of Additional Insured Person(s) Or O anization s : Location And Description Of Completed Operations "Any person or organization for whom you are perform- ing operations when you and such person or organiza- tion have agreed in writing in a contract or agreement that such person or organization be added as an addi- tional insured on your policy." Information required to complete this Schedule if not shown above will be shown in the Declarations. Section II - Who Is An Insured is amended to include as an additional insured the person(s) or organization(s) shown in the Schedule, but only with respect to liability for "bodily injury" or "property dam- age" caused, in whole or in part, by "your work" at the location designated and described in the sche- dule of this endorsement performed for that addi- tional insured and included in the "products- completed operations hazard". CG 26*37 07 04 I IIIIIII III IIIIl~~~Ilff 1~~1nd1~1 I~I~~ II II II I VIII VIII III III Page 1 of 1 ❑ Commercial Lines - (541) 685-5300 Wells Fargo Insurance Services USA, Inc. 975 Oak Street, Suite 900 Eugene, OR 97401 City of Ashland 20 East Main Street Ashland, OR 97520 1f f 1!f Yf 1!111!!11! f NIYf f! 111! f fRf f f f RNlf YYR IYRfNlf f f1f 1RlN1f N NRRR RYRY! RYRRRRYYYR RRYRYIRRf f!f 1f if f1f fNN N1f N Would you like to receive this certificate via email or fax? We offer expedited delivery to better serve our mutual clients. To update the delivery method for revisions to this certificate and for next year's copy, please enter this information in your browser: https://www.cybersure.com/cybersure/forms/iyoctcdmu.aspx When prompted, enter this information for security purposes: Client ID: 263460 Cert ID: 7478744 Passcode: 59F51888 Follow the instructions and let us know your delivery preference. You'll receive future copies of this certificate via the method you provide. Thank you for helping us provide certificates to you more quickly. Yf YY1YRRf ft1Y11tRtYYf N Rtf NRYNRRRR1ttRRRf YYRYRfttf Y1NtYf f1YY1ff YYRfNYRf 1 N1Yf 1t1f 11YNRlf YNRYRNtYYYitRRRRRRYY! OOOOt/ II IIII II II IIII III VIII II III II I (IIII I III IIII II VIII III I I III I IIII III III 'CYBLLlf1Utl10010.91INNNNO'