HomeMy WebLinkAboutInsurance Certificate: Industrial Systems
ArIC" v® CERTIFICATE OF LIABILITY INSURANCE DATE (MM1DDlWYY)
11/16/2U15
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 Employee DEFREP
NAME
(503)967-9600
PHONE (503)292-1580 AIC No:
American Benefits Inc. HO No Ext
9755 SW Barnes Rd E-MAIL
ADDRESS:
Suite 290 INSURER(S) AFFORDING COVERAGE NAIC#
Portland OR 97225 INSURERA:Libe - Liberty Northwest 41939
INSURED INSURERB Hartford Accident And Indemnit 22357
Industrial Systems, Inc. INSURERC:Indl - Admiral insurance com an
4110 Ne 122nd Ave, Ste 130 INSURERD:
INSURER E :
Portland OR 97230 INSURERF:
COVERAGES CERTIFICATE NUMBER:CL15111602225 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 MAYHAVE BEEN REDUCED BY PAID CLAIMS.
ADDL SUBR POLICY EFF POLICY EXP
IN S TYPE OF INSURANCE POLICY NUMBER MMIDDf YYY MMIDDIYYY LIMITS
X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 2,000,000
AMAG -PEN ED 2,000,000
A CLAIMS-MADE XO OCCUR PREMISES Ea occurrence $
BZS54620179 111/2015 1/1/2016 MED EXP (Any one person) $ 15,000
PERSONAL &ADVINJURY $ 2,000,000
CENLACCREGATE LIMITAPPLIEC PER 1,EP4ERFAL ^,CCRECATE $ a,nnn,nnn
X POLICY JECT ~ LOC PRODUCTS - COMP/OPAGG $ 4,000,000
OTHER Employee Benefits $
AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ 1,000, 000
(Fa accident)
X ANY AUTO BODILY INJURY (Per person) $
F' ALL OWNED SCHEDULED
AUTOS AUTOS BAS54620179 1/1/2015 111/2016 BODILY INJURY (Per accident) $
NON-OWNED PROPERTY DAMAGE $
X HIRED AUTOS X AUTOS Peracadent $
X UMBRELLA LIAB OCCUR EACH OCCURRENCE $ 2,000,000
A EXCESS LAB CLAIMS-MADE AGGREGATE $ 2,000,000
DED RETENTIONS 10 000 II006.6.0179 1/1/2015 1/1/2016 $
WORKERS COMPENSATION PER OTH-
STATUTE ER
AND EMPLOYERS' LIABILITY Y I N
ANY PROPRIETORlPARTNERIEXECUTIVE EL EACH ACCIDENT $ 11000,000
OFFICERMEMBER EXCLUDED? ❑ NIA
B (MandatoryinNH) 52WECLR7227 11/1/2015 1111/2016 E. L. DISEASE - EA EMPLOYEE $ 1,000,000
If yes, describe under
DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT $ 1 000,000
C Professional Liability E0000021111101 11/12/2015 11/12/2016 $2,000,000
A Business Interruption BZS54620179 1/1/2015 1/112016 12 Months ALS
DESCRIPTION OF OPERATIONS I LOCATIONS 1 VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required)
Certificate Holder is named as an Additional Insured with respects to the liability arising from the
operations of the Named Insured.
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
City of Ashland THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
20 East Main Street ACCORDANCE WITH THE POLICY PROVISIONS.
Ashland, OR 97520
AUTHORIZED REPRESENTATIVE
Jim Hisatomi/DEBBIE
(9) 1988-2014 ACORD CORPORATION. All rights reserved.
ACORD 25 (2014/01) The ACORD name and logo are registered marks of ACORD
INS025 (201401)