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HomeMy WebLinkAboutInsurance Certificate: Pacific Mobile Structures Inc ~i-•'~ PACIF35 OP ID: RS ACORL~` CERTIFICATE OF LIABILITY INSURANCE D01122//2012015 5 01/2 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: 360-736-7601 CONTACT NAME: Nicholson & Associates Fax: 360-330-0970 PHONE FAx 118 W. Pine Street No A/C No : Centralia, WA 985314290 E-MAIL Todd Working ADDRESS: INSURERS AFFORDING COVERAGE NAIC # INSURER A: American States Insurance Co. 19704 INSURED Pacific Mobile Structures Inc INSURER B: Attn: Nick Ververis P.O. Box 1404 INSURER C : Chehalis, WA 98532 INSURERD: 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 POLICY EFF POLICY EXP LTR TYPE OF INSURANCE POLICY NUMBER (MMIDDIYYYY) (MMIDDIYYYY) LIMITS GENERAL LIABILITY EACH OCCURRENCE $ COMMERCIAL GENERAL LIABILITY PREMISES Ea occurrence $ CLAIMS-MADE r__1 OCCUR MED EXP (Any one person) $ PERSONAL & ADV INJURY $ GENERAL AGGREGATE $ GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP/OP AGG $ POLICY PR0 LOC $ AUTOMOBILE LIABILITY ECOMBINED a accidentSlNGI E LIMIT $ 11000,00 A X ANY AUTO X 01013162925 01/31/2015 01/31/2016 BODILY INJURY (Per person) $ ALL OWNED SCHEDULED BODILY INJURY (Per accident) $ AUTOS AUTOS NON-OWNED PROPERTY DAMAGE HIRED AUTOS AUTOS Per accident $ 1,000,00 $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ OED RETENTION $ $ WORKERS COMPENSATION WC STATU- OTH- AND EMPLOYERS' LIABILITY Y I N IMIT R ANY PROPRIETOR/PARTNER/EXECUTIVE E.L. EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? - - NIA (Mandatory in NH) - E.L. DISEASE - EA EMPLOYE $ If yes, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT $ DESCRIPTION OF OPERATIONS! LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, H more space is required) City of Ashland, Oregon, and its elected officials, officers and employees as additional insured with respects to auto liability. Coverage is primary and non contributory. Job located at 95 Winburn Way Ashland, OR 97520 CERTIFICATE HOLDER CANCELLATION CITY059 [~L~~ SHOULD ANY OF THE ABOVE DESCRI LItS~S4§~C E THE EXPIRATION DATE THEREOF, City of Ashland ACCORDANCE WITH THE POLICY PRO 20 East Main St Ashland, OR 97520 AUTHORIZED REPRESENTATIVE - 2015 ©1988-2010 ACORD C RPORATION. All rights reserved. ACORD 26 (2010105) The ACORD name and logo are registered marks of ACORD