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Home My WebLink AboutInsurance Certificate: Ashland Supportive Housing & Community CERTIFICATE OF LIABILITY INSURANCE DATE (MM+OD:YVVY) 2/2/2015 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 NAN A Wauneta Ohnmacht Bliss Sequoia Insurance PHONE - _ T FAX (503)364-5401 A N . (A C. No P.O. Box 826 E-MAIL wauneta@blissinsurance.com INSURERS AFFORDING COVERAGE NAIC 0 Salem OR 97308 rINSURERA:Philadelphia Indemnit IsINSURED 9:Saif Co oration 6196 Ashland Supportive Housing 6 Community C. PO Box 3536 O: Ashland OR 97520-0318 INSURER F: COVERAGES CERTIFICATE NUMBER: (15-16) REVISION NUMBER: I-. inr sir iNSL mA;~,E LISTED BLEU" F-IaVE BEEN !SS,'D TO T I -NS IRED F.:, +ED A30VE T IE IND,CATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CFRTIFICATF. MAY RE ISSUED QR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDi IIONS OF SUCH POLICIES. LIMIT'S SHOWN MAY HAVE BEEN REDUCED BY PAID CL AIMS. INSR A DL SUER POLICY EFF POLICY EXP LIMITS- LTR TYPE OF INSURANCE POLICY NUMBER M M .YY Y GENERAL LIABILITY EACH 0i7CURRFNCF _ 1,000,000 GAA1A E 10RENTFD X 1,000,000 f'0' r.VA H,, AL t'l,%.. l3A_ L'. AkI_'. f Y f PREMISE, 'F.J oC .renCe 'i A M" MAL [XI UCCA; X i HPK1287695 /1!2015 2/112026 'A f) F01 IA~, 20,000 PLII t w N_ N jI RY 1,000,000 a I 3ENL _"t- .rE 3,000,000 A'X 3I .IA-L _IIJ+T APP_ES Ptri PRC>I 1 -tiF ,R a ;r i ; 3 000, 000 I + - T AUTOMOBILE LIABILITY 1 000 000 ANY A.7'fi R)ri v JT.RY R A i a,.l CWtifri S'HF IP rD PHPK1287695 `2/1/2015 /1/2016 tR-+ 1 . c is+n y AUTOS 4J riT ` - I FH_~F'1-H vpnt.l l.,E I r iNCTbb ht J 'U., 1 F1<a I_ I~ - _ •i-RFD C1Y:S Ali ~G X UMBRELLA LIAR FAG- _ 's)PGF ACF 1 5 1, 000, 000 A l EXCESS LIAR i i_I n n, alntit 1 000,000 - - DELILI RETP ,N. 10,00 HUB488320 /1/2015 /1/2016 B WORKERS COMPENSATION ] p TArJ _-J 7.1 I ( X AND EMPLOYERS' LIABILITY I Y an.r PRORR -Tt)R PAR Tr LR Exccl "AC ~.4L 1,000,000 -I ..-IR.rnrrJCER E 76721 /1/2014 4/1/20,.5 r- 11 F1 F =r P ^'rl 1,000 000 IM"...' in NH) N AI 000, 0o0 A PROFESSIONAL LIABILITY HPK1287695 /1/2015 /1/2016 I gal-~, )r}p pER)' I,UARENCF 3,000,000 AG ABUSE/MOLESTATION rn00cr+PER :kIC:LIHRFNcF 1,000,000 AGG DESCRIPTION OF OPERATIONS, LOCATIONS, VEHICLES (Attach ACORD 101, Additional Remarks Schedule, it more space is required) The City of Ashland, its officers, and employees are additional insureds as respects work performed on its behalf by the named insured as required by contract per PI-GLD-HS10/11. CERTIFICATE HOLDER CANCELLATION (541)552-2059 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. The City of Ashland 20 East Main St Ashland, OR 97520 AUTHORIZED REPRESENTATIVE Lance Barnwell/NETA ACORD 25 (2010'05) tiD 1988.2010 ACORD CORPORATION. All rights reserved. INS025 , i The ACORD name and logo are registered marks of ACORD PI-GLD-HS (10/11) THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. GENERAL LIABILITY DELUXE ENDORSEMENT: HUMAN SERVICES This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE It is understood and agreed that the following extensions only apply in the efent that no other specific coverage for the indicated loss exposure is provided under this policy. If such specific coverage applies, the terms, conditions and limits of that coverage are the sole and exclusive coverage applicable under this policy, unless otherwise noted on this endorsement. The following is a summary of the Limits of Insurance and additional coverages provided by this endorsement. For complete details on specific coverages, consult the policy contract wording. Coverage Applicable Limit of Insurance Page #___j Extended Property Damage Included 2 Limited Rental Lease Agreement Contractual Liability $50,000 limit 2 Non-Owned Watercraft Less than 58 feet 2 Damage to Property You Own, Rent, or Occupy $30.000 limit i 2 Damage to Premises Rented to You $ t,000,OC0 3 HIPAA Clarification; - - _ - - Medical Payments $20,000 5 - - - - Medical Payments - Exte--rdecf Reporting Pranod ~ 3 years Athletic Activities Amended I 5 Supplementary Payments -Bali Bonds $5,000 5 Supplementary Payment Loss of Earnings $1,000 per day 5 Employee Indemnification Defense Coverage $25,000 5 Key and Lock Replacement -Janitorial Services Client Coverage $1 0,000 limit 6 Additional Insured -NewtY Acquired Time Period Amended 6 Additional Insured Medical Directors and Administrators Included 7 ':nti Em log ee (.;u~erajej - Additional Insured Broadened Named Insured Included 7 _ - _ - Addrtional Insured Funding Source i Included 7 Additional Insured Home Fare Providers Included 7 i Additional Insured Managers, Landlords, or Lessors of Premises Included 7 Additional Insured Lessor of Leased Equipment Included 7 Additional Insured C,rantor o Permits Included 8 1 Additional Insured - Vendor f Included Additional Insured - Franchisor i Included 9 - _ _ + _ 11 Additional Insured - When Required by Contract ~ Included ~ g - - - Additional Insured u Deis Lessees, or Contractors Included g Additional Insured State or Political Subdivisions I Included 10 - 1_ _ - Page 1 of 12 Includes copyrighted material of Insurance Services Office, Inc., with its permission 'a 2011 Philadelphia Indemnity Insurance Company PI-GLD-HS (10111) Coverage Part, Paragraph 3.a. is deleted in its entirely and replaced by the following: a. Coverage under this provision is afforded until the end of the policy period. 2. Each of the following is also an insured: a. Medical Directors and Administrators - Your medical directors and administrators, but only while acting within the scope of and during the course of their duties as such. Such duties do riot include the furnishing or failure to furnish professional services of any physician or psychiatrist in the treatment of a patient. b. Managers and Supervisors - Your managers and supervisors are also insureds, but only with respect to their duties as your managers and supervisors. Managers and supervisors who are your "employees" are also insureds for "bodily injury" to a co- "employee" while in the course of his or her employment by you or performing duties related to the conduct of your business. This provision does not change Item 2.a.( 1)(a) as it applies to managers of a limited liability company. c. Broadened Named Insured - Any organization and subsidiary thereof which you control and actively manage on the effective date of this Coverage Part. However, coverage does not apply to any organization or subsidiary not named in the Declarations as Named Insured, if they are also insured under another similar policy. but for its termination or the exhaustion of its limits of insurance. d. Funding Source - Any person or organization with respect to their liability arising out of: (1) Their financial control of you. or (2) Premises they own, maintain or control while you lease or occupy these premises. This insurance does not apply to structural alterations, new construction and demolition operations performed by or for that person or organization. e. Home Care Providers - At the first Named Insured's option, any person or organization under your direct supervision and control while providing for you private home respite or foster home care for the developmentally disabled f. Managers, Landlords, or Lessors of Premises to their liability arising out of the ownership. maintenance or use of that part of the premises leased or rented to you subject to the following additional exclusions: This insurance Coes not apply to: (1) Any "occurrence" which takes place after you coase to be a tenant in that premises; or (2) Structural alterations, new construction or demolition operations performed by or on behalf of that person or organization. g. Lessor of Leased Equipment - Automatic Status When Required in Lease Agreement With You - Any person or organization from whom you lease equipment when you and such person or organization have agreed in writing in a contract or agreement that such person or organization is to be added as an additional !nsured on your policy. Such person or Page 7 of 12 Includes copyrighted material of Insurance Services Office. Inc.. with is permission. C 2011 Philadelphia Indemnity Insurance Company PI-GLD-HS (10111) (g) Products which, after distribution or sale by you, have been labeled or relabeled or used as a container, part or ingredient of any other thing or substance by or for the vendor; or (h) "Bodily injury" or "property damage" arising out of the sole negligence of the vendor for its own acts or omissions or those of its employees or anyone else acting on its behalf. However, this exclusion does not apply to: (i) The exceptions contained in Sub-paragraphs (d) or (tf); or (ii) Such inspections. adjustments, tests or servicing as the vendor has agreed to make or normally undertakes to make in the usual course of business, in connection with the distribution or sale of the products. (2) This insurance does not apply to any insured person or organization, from whom you have acquired such products, or any ingredient. part or container, entering into. accompanying or containing j. Franchisor - Any person or organization with respect to their liability as the grantor of a franchise to yot:, k. As Required by Contract - Any person or organization where required by a written contract executed prior to the occurrence of a loss. Such person or organization is an additional insured for "bodily injury," "property damage" or "personal and advertising injury" but only for liability ansrng out of the negligence of the named insured. The limits of insurance applicable to these additional insureds are the lesser of the policy limits or those limits specified in a contract or agreernent. These limits are included within and not in addition to the limits of insurance shown in the Declaratiors 1. Owners, Lessees or Contractors - Any person or organization, 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; it the performance of your ongoing operations for the additional insured when required by a re~rtr~ac;' 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 (a) 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 (b) 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 Page 9 of 12 Includes copyrighted material of Insurance Services Office. Inc., with its permission. C; 2011 Philadelphia Indemnity Insurance Company