HomeMy WebLinkAboutInsurance Certificate: Childrens Dental Clinic of Jackson County
01/02/2015 01:21P1,1 5417895284 CHILDRENS DENTAL CLH PAGE 02/03
88 This Spectrum Policy consists of the Declarations, Coverage Forms, Common Policy Conditions and any
05 other Forms and Endorsements issued to be a part of the Policy. This insurance is provided by the stock
FO insurance company of The Hartford Insurance Group shown below.
SBA
INSURER: SENTINEL INSURANCE COMPANY, LIMITED
ONE HARTFORD PLAZA, HARTFORD, CT 06155
COMPANY CODE: A
Policy Number: 52 SBA F00588 DX THE
HARTFORD
SPECTRUM POLICY DECLARATIONS ORIGINAL
Named Insured and Mailing Address: CHILI)Wt NS DENTAL CLINC OF
0
(No., Street, Town, State, Zip Code) JACKSON CO
Ln
° 229 STEWART AVE
MEDFORD OR 97501
Ln
Policy Period: From 12/23/14 To 12/23/15 1 YEAR
co a12:01 a.m., Standard time at your mailing address shown above, Exception: 12 noon in New Hampshire.
M
U) Name of Agent/Broker: PACIFIC BENEFIT CONSUL TAtvTrS/PHS
Code: 709710
N
N Previous Policy Number: 52 SBA F00586
0
0
M Named Insured is: NON PROFIT
Audit Period: NON-AUDITABLE
Type of Property Coverage: SPECIAL
Insurance Provided: In return for the payment of the premium and subject to all of the terms of this policy, we
agree with you to provide insurance as stated in this policy.
TOTAL ANNUAL PREMIUM IS: $500 MP
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WNW
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Countersigned by 10/27/14
Authorized Representative Date
Form SS 00 02 12 06 Page 001 (CONTINUED ON NEXT PAGE)
Process Date: 10/27/14 Policy Expiration Date: 12/23/15
INSURED COPY
bl/02/1015 01:21PM 5417895284 CHILDRENS DENTAL CLH PAGE 03/03
SPECTRUM POLICY DECLARATIONS (Continued)
POLICY NUMBER: 52 SBA F00588
Location(s), Building(s), Business of Named Insured and Schedule of Coverages for Premises as designated by
Number below.
Location: 001 Building: 001
229 STEWART AVE
MEDFORD OR 97504
Description of Business:
Medical. Office - Dentist
Deductible: $ 500 PER OCCURRENCE
BUILDING AND BUSINESS PERSONAL PROPERTY LIMITS OF INSURANCE
BUILDING
NO COVERAGE
BUSINESS PERSONAL PROPERTY
REPLACEMENT COST S 187,100
PERSONAL PROPERTY OF OTHERS
REPLACEMENT COST NO COVERAGE
MONEY AND SECURITIES
INSIDE THE PREMISES $ 10,000
OUTSIDE THE PREMISES $ 5,000
Form SS 00 02 12 06 Page 002 (CONTINUED. ON NEXT PAGE)
Process Date: :0/27/14 Policy Expiration Date: 12/23/15