HomeMy WebLinkAboutInsurance Certificate: Pacific Retirement Services
® DATE (MMIDDNYYY)
ACORr>► CERTIFICATE OF LIABILITY INSURANCE
12/18/2015
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 CONTACT
NAME Underwriting Associate
Caring Communities Shared Services LTD
PHONE Xt) 847-549-8225 J C No) 847-549-8095
1850 W Winchester Road INC No F
Suite 109 EMAIL Certificates Cann comm or
ADDRESS @ 9 g
Libertyville IL 60048
INSURERS AFFORDING COVERAGE NAIC #
INSURED Pacific Retirement Services Inc. INSURER A Caring Communities. A Reciprocal RRG 12373
Community Volunteer Network INSURER B
One West Main St
INSURER C
Suite 303 INSURER D
Medford OR 97501 INSURER E
COVERAGES CERTIFICATE NUMBER: REVISION NUMBER:
THIS IS 10 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 MAY HAVE BEEN REDUCED BY PAID CLAIMS
INSR TYPE OF INSURANCE ADO'L SUER POLICY NUMBER POLICY EFF POLICY EXP LIMITS
LTR INSR WVD MMIDONYYY MM/DDNYYY
GENERAL LIABILITY EACH OCCURRENCE S 1,00000000
A CCRRRG-0015-16 01/01/2016 01/01/2017 DAMAGE TO RENTED S
COMMERCIAL GENERA: ! ! AEiLTTY X
X
PREMISES IEa occurrence 300.000 00
X CLAIMS MADE GCC UR MED EXP fAry one person s
X Professional Liability PERSONAL s ADV INJUPO s 1,000.000 00
X Retro Date 0110112002 GENERAL AGGREGATE 5 3,000.000 00
GENL AGGREGATE LIMIT APPLIES PER PRODUCTS - COMP;OP AGG 5 incl
X POL~CV PRO- LOC $
JECI
AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT
(Fa accioeni; s
ANY AUTO BODIL'r INJURY (Per person) S
ALL OWNED SCHEDULED
AUTOS AU-OS BODILY INJURY (Per accltlent) S
HIRED AUTOS NON OWNED PROPERTY DAMAGE S
AUTOS IPer accltlent
5
EXCESS I UMBRELLA LIABILITY EACH OCCURRENCE $
CCRRRG-0015-16 01/01/2016 01!01/2017 10.00000000
A UMBRELLALIAE 8 OCCUR X
AGGREGATE $ 115.000
X EXCESS LIAB X C,-AIMS MADE s
S
DEDUCTIBLE
RETE%-,O',
5
WORKERS COMPENSATION ANDA,'r S-ATiJJTn
EMPLOYERS' LIABILITY YIN TORY LIMITS ER
AN'Y PRCPR,ETOR' PARTNEF.'E XECUTIVE ❑
OF FICER'MEMBER EXCLUDED- EL EACH ACCIDENT s
(Mandatory in NH) E L DI
SEASE EA EMPL CY EE 5
It yes oescr.oe „noes
SPECIAL PROVISIONS b-, EL DISEASE - POLICY LIMIT Is
OTHER
DESCRIPTION OF OPERA PONS; LOCATIONS' VEHICLES ;EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS
12/18/2015 10 2326
The Certificate Hccf r is PCUdeo as an Aod-tonal INSURED under this POLICY but o-,ly with respect to 6abi n, ans,ng oU: of services rendered by the Nareed INSURED as
outlined unhn ithe terms and condn.c-S of the cont(actuai agreement 'a the Foster Grandparent program hetween the City of Ashland and the Named INSURED
CERTIFICATE HOLDER CANCELLATION
The City of Ashland SHOL'ILD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF NOTICE WILL BE DELIVERED IN
20 East Main Street ACCORDANCE WITH THE POLICY PROVISIONS
Ashlana OR 9752C
AUTHORIZED REPRESENTATIVE
J 7
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