HomeMy WebLinkAboutInsurance Certificate: Grayback Forestry (2)
1 ® DATE (MMIDDIYYYY)
~+►coRO CERTIFICATE OF LIABILITY INSURANCE
12/22/2015
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). CUNTA
PRODUCER NAME: Kendall Pori
Protectors Insurance, LLC HONE Ext:541-842-2963 arc N6:541-772-1906
A/C, N
P.O. Box 4669 E-MAIL
Medford OR 97504 ADDRESS:kendall rotectorsins.com
INSURER(S) AFFORDING COVERAGE NAIC #
INSURERA:Amerlcan States Ins Company 9704
INSURED GRAYB-1 INSURERB:American Economy Insurance
Grayback Forestry Inc INSURER G:
Western Emergency Services LLC INSURER D:
PO Box 838
Merlin OR 97532-0838 INSURER E:
INSURER F :
COVERAGES CERTIFICATE NUMBER: 1621780351 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.
POLICY EFF POLICY EXP
INSR TR TYPE OF INSURANCE INSR WVD POLICY NUMBER MMIDDIYYYY MMIDDIYYYY LIMITS
OCCURRENCE $1,000,000 'T r,
A GENERAL LIABILITY 01-CI-311182-70 1/112016 1/1/2017 Lan)
X nce $1,000,000
COMMERCIAL GENERAL LIP,BILITY
P F" IF
DE ~ OCCUR son) $10,000
CLAIMS-MA
URY $1,000,000
TE $2,000,000
GEN'L AGGREGATE LIMIT APPLIES PER. PRODUCTS - COMP/OP AGG $2,000,000
PRO- Loggers Broad Form $1,000,000
LOC
POLICY X 7
B AUTOMOBILE LIABILITY 02-CE-22830440 1/1/2016 1/1/2017 (Ea accident) $1,000,000
X ANY AUTO BODILY INJURY (Per person) $
ALL OWNED SCHEDULED BODILY INJURY (Per accident) $
AUTOS AUTOS PROPERTY DAMAGE
NON-OVWNED P PERTYt $
H[RED AUTOS AUTOS $
A UMBRELLA LIAR X OCCUR 01-SU-417057-70 1/1/2016 111!2017 EACH OCCURRENCE t000
EXCESS LIAB CLAIMS-MADE AGGREGATE DED RETENTION WORKERS COMPENSATION WC STATU- OTH-
AND EMPLOYERS' LIABILITY YIN TORY LIMITS ER
.
ANY CERWETORI RXECUTIVE E L EACH ACCIDENT $
❑ NIA
(Mandatory in ER EXCLUDED?
(Mandatory in NH) E.L. DISEASE- EAEMPLOYEE $
DESCRIPTION OF OPERATIONS below E.L. DISEASE-POLICY LIMIT $
DESCRIPTION OF OPERATIONS 1 LOCATIONS 1 VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required)
City of Ashland is listed as additional insured per CG7635 0207
Project: #AFR-TSA-UB-2015-Unit 12
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
City of Ashland ACCORDANCE WITH THE POLICY PROVISIONS.
455 Siskiyou Blvd
Ashland OR 97520 AUTHORIZED REPRESENTATIVE
0611988-2010 ACORD CORPORATION- All rights reserved-
ACORD 25 (2010105) The ACORD name and logo are registered marks of ACORD
M Insu ante COMMERCIAL DENERALLIABILfTY (b) Ths insurance does not apply to Tlts exdm!an Applies even IF Fla ciafrns
a CG 76 35 02 07 'bod;ly Injury" or property daa- - against any Insured allege Wigencer or
Aga- Af hl,y uul ur U. Gut. neyr- atoa' wrongdasag . ew stp?.vPohn- Mind.
gerce o such person or employment tratcmg « nror y.orltg of orhors
«ganaaton; by that tenured, N the •cccwrence• nitlrh
ury,
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ R CAREFULLY. used thee 'eddy Ml vvn property
(4) Petmi's sstxd by arty tOS « pd;tiwl damage' trroNed the ownersfup. mabtie-
subdhAsion wth respect to operation nuance, use or earwn rent to of ews of arry
LIABILITY PLUS ENDORSEMENT performed by you or on your behay, Aircraft, `auto" or watercraft that Is wined
aubject to U» Wsoeeim Additional pro- or operated by or rented Or band to any M-
viejo owed.
Tns eMOtsemsnt mo9fles insurance provided aasder the fosoW trig
Ttis Msuraroa does not Apply to 'bod%ry TNS exclusion dies not apply W.
COWVIERCW. GENERAL LIABILITY COVERAGE PART Mlwy, )xoPery darraga or (1) A vrztereraft %t0o ashore oo premises
'personal And Advardslng Injury` arcing you On or rent
SCHEDULE out of cpstatlons performed for the sae y
« run'': aWgy. (2) A watercraft you do not on that Is:
leas u,d, Oz rcpt vr,y; a,ad
Name of Person or organbatl-: c Tin Insurance wit" 'aspect to arty arch Act, (a)
eng-, or surveyor added As an Muted (b) Not befog uted to carry prisons of
by this endorsement does not Apply to property for a charge;
BLANKET-PER CERTIFICATE OF INSURANCE 'LOdy fnjury•, 'propem darega•, « per-
Aone) " advertising Injury, erasing Cut of (3) Parfung an 'auto' on, or on 0me ways
the rendering of or the failure to rander am/ next to, Premises you osm of rent, pro-
Professional eervkes by or for you, icciud- tided the Is not ormed by or
rao< or rvanad ao yr„ nr tea s,<nrm:
rig'
(t) The prpadng, approving. or fetrg to (4) Uab7y assured under Any 5nsured
prepare or Approve craps, duMngs, contract' for the awn mitip, mants-
opinforn, reports, strvoys, change or- name or uaa at alrua,9 or waleruah; or
ADDITIONAL INSURED - BY WRITTEN Lass or dens, designs or operihcaGCns; and (5) •Bodl/ Injuy or `property damage"
occupy, subject to the fo¢owing wising out or:
CONTRACT, ACnZGMGN`r OR PERUrr, r1R r+N'rRanal prwkloni' (2) SLT-,Wry, inspection or En&wi g
SCHEDULE a Ths Iruswartce does not a to 6en' s a,s opcroLvn of r„-an, or
apply equ!p roam that k e°ached to, or
The folaAing paragraph is added to Yr'io IS AN any bccumenca* wflkh takes pace d. Ths Irswance does not eppry to ,bdiy pan of, a Tana vWcla that would
INSURED (S-ton II): alter you cease to ba a tenant In Injury' or 'property damage' Included ni',hin qualify under the dcfni^.. or
am/ prsm'ses Lased to cr ~en!ad to the pnoductscomple!ed operations ha.- 'mobile 61u"M, V h were not
4. An/ parson or wgarka)- shove M U. Sched- YOUI and.. sulKed to a compulsory or financial
Ufa or for wfom you Are reguked by rilten con (b) Thls Insurance not Apply to responsbirry tan or other motor ve-
u:,_ , ag--'t err perms to prrv___ m sin y sx twvf arseamnw. n-ra non- A Parson's n n.u=nna,'nr;s crank as an Insured w- hcfs Ineurance Raw In the state
is an ensured, subject to Lha faovdng add;dunal struceon « demwswn cparations der this endorerr.G,t ends neon your erera•_sms for where k s Iczn-d! or prindpey
prorlsions- performed by or co befall of We that Insured are coerpte!ed. garaged; or
A. The Contract, Agreement « yenta must be Panson or orgwLadw added as an (b) the CparaEon of my of oa machht-
In Ofed during Ina policy period shown In Ins'ned! No o>•renaga ni' be provided d. M the absence of ors Cry err equ-p-L Psted h Paragraph
the DeeTwa5nns, and mist have been exe• (2) Your orgo'ng operations for that Ire endorsement no 6abTty would baImpo=_ed by law c0 f.(2) or f{3) of t7» de<.n'Son of
cured Prior to the 'bcdN In1uY. properc/ awed. whether the rorc 6 performed you. Coveraga sha7 ba (enr±sd to the wda,t o you •rnobdo equlprnenl`.
damage', or `personal a ads mg 6y you «f« you; need- a Is,, h act &,o to tre Appl',cab'a Dane(- plea araait Co rot own lnl-u ¢ h
of ttmpara!Pre fault (6) An operated by by arty InsuredA
(3) The ma re, Operation or use by not
In. The person or «ganlza5on added Insuas anW you oequTpentLased to you by suce NON-OWNED LI WATERCRAFT AND NON435VNED
Awed bj d,IS Endorsement s an en hawed only person or « orn rnrganlza5ort, sLbec[ to tea AIRCRAFT LIABILITY LITY TENANTS' PROPERTY DAMAGE LIABILITY
to the odent you are head Uawo dus to: fotlomog adddoral prwlsbnz
(1) The ownership. watr!enance or use of (a) 71sis Insurance does not apply to E Uue,- g. of COVERAGE A (Sec`- IJ Is te,daced _g
afonn M the ee To Peer i es R U.-:ed oo You UrratIs
C vl pun 0 p<~rda<s you Awn, tens ,y •u.ua,a wlxhJe lo-tea p,o<e by U. fel;onina: A. &n In t b r< d cl' to T
ng-
p'ox ty too
.her the eq,rpmert feria aspUes; C. •BOddy Injury" or `property damage' Arising
out of led vwnerhJp, mah!enaroe, use « f- Damage To Property
er'wlrnem to ohs of any ."Craft •aW.o" •Propery, d-age• by
or srateraa2 armed or operated by cr rented
Includes Copyrighted Va!ai d of Insurance Services Offce, Inc., with its pe,,rj.lal « loaned to Any Insured. Use Induces cper- (1) Property you own. rent, or occupy,
hdW ng _
Cop/rght, Insurance Services, 2001 atop and 'loading or wioadlirT. cry toss or e;`p-es Incurred by you, or
ah. w r. se.. qe ,Sm<,s rd.~v d zoo t
03 76 SS It rr Pr;e / d r En
P;e i a,
CG7635(0207) pdf CG7635(0207) pol
any other person, ofWize6on or entity, f« WHO 15 AN INSURED - MAMAS ERS EXTENDED DEFINITION OF BOOiLY INJURY Intairupted only by a street, roadvsy. waterway, or
repair, repmacerren% whancerren% festc - rg"t-of-way of araaroad.
Lion or maAot arxv of each propany for any The Wo irg k added W Pa.regnph 2- 4 NArJ Lq Pa,-q,.rh 3. of 1)FPNrr4'eA (Secdnn V) k replaced
reason. IrxsuSng prVVVI n of Injury to a AN INSURED (Section fl): by the following. INCREASED MEDICAL EXPENSE LIMIT
Person «damage to anodw's property;
(2) Pramises you sea, give array or ebaMOn, N Paragraph (1) does cwt apph/ to ""e eee O"Cers, or 3. 'Sodfy iyu r means bodiy tr>j,Ay, elckrsass « The Medical Expense Un is
9m6nded l0 510,000.
the property damage' arras red of any part to marragm, at fire supervsory feral « above. dis asa sus!a!ned by a person, lxk;,J ng renal
of those premses; Anguish or death rest9rM from any of these at KNOWLEDGE OF OCCURRENCE
SUPPLEMENTARY PAYMENTS - COVERAGES A Ary L".
(3) 1`1P iy Ira sad to You, AHD 9 - 9A6L HONn3 - True rice FROM D. fatoMno Is Added to Paragraph 2. Ovf.;vs In The
(4) Personal property In N care cw;Lod,/ or WORK TRANSFER OF RIGHTS OF RECOVERY Evan Of Occutle-D. Offense, Carm Of Suit of
Control of the hst.+ed; tA6shIERCIAL GENERAL LIASIUTY CONDITIONS
Paragraph tA, of SUFPLEMENTARY PAYMENTS - The fouowi,g Is added to Paragraph & Transfer Of (Section IV):
(5) Ths t particular part Of real property on which COVERACES A AND B Is replaced by ore folF;ning: Rights Of Recorery Against O'JWS To Us of M%!-
you or am/ certrne ofs « subconbaoors MERCIAL GENERAL LIABILITY CONDITIONS (Sec- KwMedge of an `occurrence', calm or `srdt• by
wodxing drectty or Ind'-tfy an your behal 6. Up to S3,cw For Cost of bar bonds requred Gen IV): Y" agent, servant Or employee .fall not In Itself
are cerfarmino opera5ons. it the 'property because of acc den's « Ir.Tyc law %tlatOns co.Tstr',u,e k-ledw 01 the named Imured unfeas an
damage else. Cut of IMSa opsrs1;ons, or arls'ng ow or vine use of any vshkse w .16"' Wo noire an/ rghls of recovery we may have agxrt;t CS"„cAr of ft named y surz0 has recerced
such nonce
the EeSy l^, Ua`^Ay Coverage epp[es. Amy person or Crgenbadon because of Payments we from the a nt, servant ur ur o tie
(6) That particular part of my p,.Wi that must We do not have to Ilm,sh these bonds. g`- y
he restored, repaired or replaced because make for injury or <aTagro Arising out of your t wed
your woe's' was McorrecUj pert«rned on It, Paz.9raPh 1.d. of SUPPLEVENTAFTY PAYMENTS - that waders or « your r Avk nickn ` darns order a contact with UNINTENTIONAL FAILURE
TO DISCLOSE ALL
-c led operations aria IrKXPI^d TN In n HAZARDS
Paragraphs (1), (3) end (4) of olds excuslon do (AVERAGES A AND B U replaced by the iCSOnMg: prodducsuctsocmpieted operations hazardrd". , this wa"rer
not scow to bropeny damege• (other than d. An reasonable exneruses Inawted br the lo- apples ordy to a person or «gardzasw, for wt'wm you TIy folfawtng is added to Pwag
aph 6. Rtepreseia-
damage icy fire) to premises, Intl d i; Iho con- sured at oar request to essW us M the In- are regww ny nifit6n corxracA agreement or petrrst tiona of COtt~UERCIAL GENEf7Al
LIA51UlY CUNUI•
Isola of such promises, rented to )ou. A separate vsstga>on «de'ense of the Balm or 'suit', 1. waive tr ese rghs of racalary. TIONS ($%Son IV):
emit Cf Fnsuranoe aW- to Damage To Pt- lrxludfig Actual loss of earn'rgs up to Sam
lees Rented To You es des ,b d h Section 10 a day because Of time 0 from WWI- AGGREGATE LIMITS OF INSURANCE - PER IF you urJn!entonaIy fall to dscloee arty hazards ex-
- u7ft Of Insurance. LOCATION
stgy at tiro McepGOn data of your Fairy, woe niil not
Paragraph (2) of this exrtlusial does rot Apply IF EMPLOYEES AS INSUREDS - HEALTH CARE ` del coverage tmdar INS Coverage Form because of
v-a PrcmlcC> tiro yew uric • and .wro nova SERVICES For all sums which the insures bermes kyatI W'i- such faIve. Hovover, th:s prc ihj m dons not affect
occupied, rented or ha?d For renal by you. Based to Pfi As Coinages caused uy 'tn r;u„c,wa- «x rtght to wFe t ada:«W premium or exc-rcloe our
, , and of guts exchubn Provision 2..(1J(d) of WHO IS AN INSURED (Section "at COlEERAA Aans I~ foCOVERAGE r 93 msd'CC rot of cance7a6on or
Para nonrenotir'.
9rerPIns (J) 141 (5) 16) 6) s dele`t d, trJ,, excludid by separate endorse- euporses caused by e~
do not apply to fabi<y assumed under a side- manL (Section q, nhlch Can be attrbuted only to cperations LIBERALIZATION CLAUSE
track agreement ate single iocatonn
Paragraph (6) of this a Ouslorf does rot apply to EXTENDED COVERAGE FOR NEWLY ACQUIRED The following paragraph Is added to WJMERCAL
yrepeny dun>ae• Inca,dad u, u~ yroe.c,<. ORGANIZATIONS Paragnaphs 2.A. end 2b. of 1-Innis of Insurance (Sec- GENERAL UA<IY CONDMONS (Section N):
compte!ed operations razaM'. U- erg apply ecp~a, y w .-1, or yaw •wwsona•
raASlon 3.a G WHO IS AN INSURED (SecSOn a) Is o-ed by or rented to you 10. N a revision to tnIS C%s rage Part, which wouid
GOn IfIJ Fries b'1 the fo HO IS Plo.%, more Coverage With M addi5onal Pre-
Paragraph 6. of LIMTS OF INSURANCE (Sec P
s replaced by One to tow rig' e. Gayer rder Ms slon Is afforded -Lo-at'on• rems premsas tmolv'.ng the Sams or miwn, becomes eRectiva during the potty Perod
cctiny toys, or promises Wilosa connexion Is In the s'a'le shovm In U's DLCLwAtiors, your POI-
pro . com;
6. SAW to 6, above, the Damage To Premis6s only ra the end of s the PfcY Perlod Icy Wit Automatically prwlde IN$ 6ddii00al C01-
Rented To You Urnk Is the most we MI pay urn C CNOIID •PRi0f`MTY DAW.or^ stage on the eHec We date of the rer lsbn.
d& Coverage A for damagea because of
`property damage" to any ore premises, where Exclusion a. or COVERAGE A (Seddon f) Is replaced
ed toy or In the ace of damage by fire,
While ratted to you ernporanTy oauped by by the bbning
you Mdh permksion of the ovner. a 'Bodily Injury` «'prop" damage` expected
or Intended Damagge To Promises Rented To You tirnA s dine from the ifaMpcht of the Insured.
higher of the Each Occwfana Umit shown h the This exohslon does riot apply to wm&ly Injury,
Deuara!ions «1he emowt ahem in the Declared- «o~~ darraga' fewF'nq from flea use d
es Damage To Premises Rented To You Lim i easonabk force to protect pc sans «p prop".
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CG7635(0207).pdf CG7635(0207) pdf