HomeMy WebLinkAboutInsurance Certificate: Modular Space Corporation
ACOR°® CITY RECORDER oATE(MMDOnrVY)
CERTIFICATE OF LIABILITY INSURANCE page 1 of 1 03128/2014
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(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 CONTACT
NAME
Willis
of Pennsylvania, Inc. PHONE FAX
c/o 26 Century Blvd. 877-945-7378 888-467-2378 NO) P. o. Box 305191 MAIL a rtificates@willis.com
AnnRFqq' Nashville, TN 37230-5191
INSURER(S)AFFORDING COVERAGE NAICX
INSURERA: Zurich American Insurance Company 16535-006
INSURED Modular Space Corporation INSURERS: American Guarantee & Liability insurance 26247-005
1200 Swedesford Road INSURER C:
Berwyn, PA 19312-1078
INSURER D:
INSURER E:
NSURERF:
COVERAGES CERTIFICATE NUMBER: 21378934 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.
INSfl TYPE OFINSURANCE DD' SUB POLICY NUMBER POLICY EFF POLICY EXP LIMBS NqRT -IUD A GENERAL LIABILITY GLO 5747082 Ol /30/2014 3/30/2015 EACH
OCCURRENCE $ 11000,000
X COMMERCIAL GENERAL LIABILITY DAMAGETOED
PREMISES ERa oxENTurence $ 300,000
CLAIMS-MADEIXI OCCUR MED EXP(Any one person) $ 10,000
PE RSONAL If ADV INJURY $ 11000,000
GENERALAGGREGATE $ 2,000,000
GEN'L AGGREGATE LIMIT APPLIES PER PRODUCTS-COMP/OPAGG $ 2,000,000
X POLICY PRO LOC
A AUTO MOBILE LIABILITY BAP 5747081 Ol 3/30/2014 3/30/2015 COMBINED SINGLE LIMIT
Ea accident) g 2,000,000
X ANVAUTO BODILY INJURV(Perperson) $
ALLOWNEO SCHEDULED
AUTOS AUTOS BODILY INJURY(Per accident) $
X HIREDAUTO$ X NON-0WNED OAMA E
AUTOS Peraxident) $
$
B X UMBRELLALIAB X OCCUR AUC 5747218-01 3/30/2014 3/30/2015 EACH OCCURRENCE $ 5 000 000
EXCESS LIAR CLAIMS-MADE AGGREGATE $ 5,000,000
DED RETENTION$ $
A WORKERS COMPENSATION WC 5747083 01 3/30/2014 3/30/2015 X
AND EMPLOYERS' LIABILITY YIN
A ANY PROPRIETOR/PARTNEWEXECUTIVE N/A WC 5747084 01 3/30/2014 3/30/2015 E.L. EACH ACCIDENT $ 1,000,000
OFFICER/MEMBER EXCLUDED?
MandatoryIn NH) E.L. DISEASE - FA EMPLOYEE $ 11000,000
~f yes, de nhe under
DESCRIPTION OF OPERATIONS Imlow E.L. DISEASE - POLICY LIMIT $ 11000,000
DESCRIPTION OF OPERATIONS/ LOCATIONS/ VEHICLES (Attach Acord 101, Addkonal Remarks Schedule, if mom space I. required)
Re: Lease #190179
Subject to their terms and conditions, the above referenced liability policies (excluding Workers'
Compensation and Employers Liability) include Ashland Parks and Recreation as Additional Insured in
regards to work performed by employees, agents and subcontractors of MSC in the course of
delivering, installing, repairing and/or removal of modular buildings leased or purchased from MSC.
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
Ashland Parks and Recreation AUTHORIZED REPRESENTATIVE
Attn: Kari Olson
90 N. Mountain Ave.
Ashland, OR 97520
Coll:4375520 Tpl:1788931 Cert:21378934 0 1988-2010ACORD CORPORATION. All rights reserved.
ACORD 25 (2010/05) The ACORD name and logo are registered marks of ACORD