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HomeMy WebLinkAboutInsurance Certificate: Lomakatsi Restoration Project (2) AC a CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DDNYYY) 4/16/2014 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 endorsements . PRODUCER NAME: Protectors Insurance, LLC PHONE FAX P.O. Box 4669 Exn-541-773-5358 A/C No),541-772-1906 E-MAIL Medford OR 97504 ADDRESS: INSURERS AFFORDING COVERAGE NAIC e INSURERA:FirSt atiQnal Insurance Go 24724 INSURED LOMAK-1 INSURER B Lomakatsi Restoration Project INSURER C: Justin Cullumbine INSURER D:SAIF Corporation PO Box 3084 Ashland OR 97520 INSURER E: INSURER F : COVERAGES CERTIFICATE NUMBER: 1108014975 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 rypE OF INSURANCE ADDL SIIBR POLICY EFF POLICY EXP LTR IN SR VND POLICYNUMBER MMMONYW MM/DDNWY LIMITS GENERAL LIABILITY 5CC1600448 117/2014 /17/2015 EACH OCCURRENCE $ DAMA E T RENTED COMMERCIAL GENERAL LIABILITY PREMISES Ea occumm. $ CLAIMS-MADE FIOCCUR MED EXP (Any one person) $ PERSONAL B ADV INJURY $ GENERAL AGGREGATE $ GEN'L AGGREGATE LIMIT APPLIES PER PRODUCTS -COMP/OP AGG $ POLICY PRO LOC $ COMBINED SINGLE Ea accident B AUTOMOBILE LIABILITY 04CC2285274 117/2014 /7/2015 LIMIT ANY AUTO BODILY INJURY (Per Person) $ ALL OWNED SCHEDULED AUTOS AUTOS BODILY INJURY (Per accident) $ NON-OMED PROPERTY DAMAGE $ HIREDAUTOS AUTOS Per acdent C UMBRELLA OAS OCCUR 01 SU36914300 /17/2014 /17/2015 EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTIONS $ IM _ D WORKERS COMPENSATION 92153 /1/2014 /1/2015 WCSTATU- DTH- AND EMPLOYERS' LIABILITY Y / N S1 I ANY PROPRIETOR/PARTNER/EXECUTIVE ❑ NIA E.L. EACH ACCIDENT $ OFFICERIMEMBER EXCLUDED? (Mandatory in NH) - / E1 . DISEASE - EA EMPLOYE $ If yes, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT $ DESCRIPTION OF OPERATIONS / LOCATIONSI VEHICLES (Attach ACORD 101, Additional Remarks Schedule, If more space Is required) As additional insured per policy endorsement CG7635(0207): CERTIFICATE HOLDER CANCELLATION 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. 20 East Main St Ashland OR 97520 AUTHORIZED REPRESENTATIVE Maus (•Ia.l.Crr.J's.( .~n..T..,e, ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25 (2010/05) The ACORD name and logo are registered marks of ACORD