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HomeMy WebLinkAboutInsurance Certificate: Pacific Mobile Structures Inc (2) Client#: 704959 PACIFMOB ACORD. CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) 1/26/2015 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: USI Northwest CL1 (A/C, PHONE Ext : 503 224-8390 AFAX /C, ,):610 362-8130 700 NE Multnomah, Suite 1300 A p1ESS, angela.christiansen@usi.biz Portland, OR 97232 INSURER(S) AFFORDING COVERAGE NAIC # 503 224-8390 INSURER A : American Economy Insurance Comp 19690 INSURED L INSURER B : American Insurance Company 21857 Pacific Mobile Structures Inc INSURER C : Liberty Northwest Insurance Cor -41939 P.O. Box 1404 INSURER D 1554 Bishop Rd. INSURER E Chehalis, WA 98532 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 CONTRACTOR 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. IN SR ADDL SU R POLICCY EFF POLICY EXP LTR TYPE OF INSURANCE INSR WVD POLICY NUMBER YYY) _ MM/DDNAYY LIMITS A GENERAL LIABILITY 01C131839060 113112015 01131/201 EEACH~~OEE000RRENCE S1,000 :UQQ X! COMMERCIAL GENERAL LIABILITY p PREMISESEaoccccurrence s200000 CLAIMS-MADE 17 OCCUR MED EXP (Any one person) $10,000 X!, WA Stop Gap $1 MM _ PERSONAL &ADV INJURY $1,000,090 GENERAL AGGREGATE S2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP/OP AGG S2,000,000 _ PRO- POLICY n JT LOC Is - AUTOMOBILE LIABILITY - - Ea aBINN accident) SINGLE LIMIT $ _ ANY AUTO BODILY INJURY (Per person) $ ALL OWNED SCHEDULED AUTOS ALTOS BODILY INJURY (Per accident) $ NON-OWNED PROPERTY DAMAGE HIRED AUTOS AUTOS Per 'I - S I $ B UMBRELLA UAB X OCCUR SU048773568 1/31/2015 01/31/201 EACH OCCURRENCE S5009000 EXCESS LIAR CLAIMS-MAD AGGREGATE s5,000,000 DED RETENTION $ $ WORKERS COMPENSATION WC41 NCO18531 Dl/31/2015 01/31/2016 X WC STATU- OTH- AND EMPLOYERS' LIABILITY Y / N TOBY I ANY PROPRIETOR/PARTNER/EXECUTIVE E.L. EACH ACCIDENT S1 OOO QQQ OFFICER/MEMBER EXCLUDED? LN N/A (Mandatory in NH) E.L. DISEASE - EA EMPLOYEE $1,000,000 If yes, describe under DESCRIPTION OF OPERATIONS below _ E.L. DISEASE - POLICY LIMIT $1,000,000 A Installation OIC131839060 1/31/2015 01/31/201 $1,000,000/$1000 Ded DESCRIPTION OF OPERATIONS/ LOCATIONS/ VEHICLES (Attach ACORD 101, Additional Remarks Schedule, If more space is required) The City of Ashland, Oregon, and its elected officials, officers and employees are additional insured as respects the operations of the named insured. CERTIFICATE HOLDER CANCELLATION City of Ashland SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 20 East Main Street ACCORDANCE WITH THE POLICY PROVISIONS. Ashland, OR 97520 AUTHORIZED REPRESENTATIVE 01988-2010 ACORD CORPORATION. All rights reserved. ACORD 25 (2010/05) 1 Of 1 The ACORD name and logo are registered marks of ACORD #S14232726/M14232429 RRBZP POLICY NUMBER: 01CI31839060 COMMERCIAL GENERAL LIABILITY CG 20 10 07 04 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - OWNERS, LESSEES OR CONTRACTORS - SCHEDULED PERSON OR ORGANIZATION This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Name Of Additional Insured Person(s) Or Organization s : Locations Of Covered Operations As per written contract Information required to complete this Schedule, if not shown above, will be shown in the Declarations. A. 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", "property damage" or "personal and advertising injury" caused, in whole or in part, by: 1. Your acts or omissions; or 2. The acts or omissions of those acting on your behalf; in the performance of your ongoing operations for the additional insured(s) at the location(s) designated above. B. With respect to the insurance afforded to these additional insureds, the following additional exclusions apply: This insurance does not apply to "bodily injury" or "property damage" occurring after: 1. All work, including materials, parts or equipment furnished in connection with such work, on the project (other than service, maintenance or repairs) to be performed by or on behalf of the additional insured(s) at the location of the covered operations has been completed; or 2. That portion of "your work" out of which the injury or damage arises has been put to its intended use by any person or organization other than another contractor or subcontractor engaged in performing operations for a principal as a part of the same project. This insurance is primary and non-contributory. CG 2010 07 04 © ISO Properties, Inc., 2004 COMMERCIAL POLICY NUMBER: OICI31839060 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) Location And Description Of Completed Or Organization(s): Operations As per written contract 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 damage" caused, in whole or in part, by "your work" at the location designated and described in the schedule of this endorsement performed for that additional insured and included in the "products-completed operations hazard". CG 20 37 07 04 © ISO Properties, Inc., 2004 ©Insurance Services Office, Inc. 02011 Vertafore, Inc. All Rights Reserved.