HomeMy WebLinkAboutInsurance Certificate: Barrett Business Services Inc
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July 13, 2015
AMERICAN INDUSTRIAL DOOR LLC
5022 TABLE ROCK RD
CENTRAL POINT, OR 97502-9413
Re: Barrett Business Services, Inc. ("BBSI")
Letter of Self-Insurance for Workers' Compensation Coverage
As the named addressee of this Letter, your company's required workers' compensation coverage is provided
through BBSI's state approved Self-Insured Workers' Compensation Plan by way of your co-employment
contract with BBSI. Additional information is as follows:
State: Oregon Workers' Compensation Limits: Employer Liability Limits:
Self Insurance Certification 1068 Statutory $5,000,000.00 Each Accident
$5,000,000.00 Disease Coverage Limit by Client
$5,000,000.00 Disease; Each Employee
Other Comments (place an "X" if applicable):
Named "Letter Holder": CITY OF ASHLAND 455 SISKIYOU BLVD ASHLAND, OR 97520
aX Other: RE: City Yard Shop.This letter of self-insurance for workers' compensation insurance replaces Acord form
25. Contract effective 6/22/15, renewal date 6/30/16. Subject to 30 days' notice of cancellation.
Additionally, BBSI's self-insured program is further supported by an excess workers' compensation insurance policy with
ACE American Insurance Co.. Copy of certificate is available upon request.
For additional information, please contact your local BBSI office at: MEDFORD
(541) 772-5469
3512 Excel Drive Suite 107
Very truly yours, Medford, OR 97504
Michael L. Elich
President and Chief Executive Officer doc. LOST