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HomeMy WebLinkAboutInsurance Certificate: Park Avenue Turf n:George Petersen Insurance Agency To:Park Avenue Turf, Inc. (15414885320) 14:20 12/28/15 GMT-08 Pg 2-4 PARKAVE-CL HFAHY ACOR~' CERTIFICATE OF LIABILITY INSURANCE DAT1E (MMlD(MMIDDIYYYY) /YY F 2/28/2015 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(les) 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: George Petersen Insurance Agency, Inc. PRONE 525-4150 p/c Nu ; 525-4175 P.O. Box 3539 AIC No Ell : (707) (707) Santa Rosa, CA 95402 E-MAIL SS: info@gpins.com INSURER(S) AFFORDING COVERAGE NAIC p INSURER A Nationwide Agribusiness Insurance Company 28223 INSURED INSURER B Pacific Compensation Insurance Company Park Avenue Turf, Inc. INSURER C P.O. Box 2198 INSURER D Sebastopol, CA 95473 INSURER E : INSURER F : COVERAGES CERTIFICATE NUMBER: 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 MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR POLICY EFF POLICY EXP LTA TYPE OF INSURANCE INSD WVD POLICY NUMBER (MM/DDIYYYY) (MM/DDIYYYY) LIMITS A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE ❑ OCCUR X FPK7835544318 0410812015 04108/2016 PREMISES Ea occurrence $ 100,000 MED EXP (Any one perscn) $ 5,000 PERSONAL & ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 X POLICY [ PROECT LOC PRODUCTS - COMP/OP AGG $ 2,000,000 OTHER_ $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ 1,000,000 Ea accident A X ANY AUTO FPK7835544318 0410812015 0410812016 BODILY INJURY (Per person) $ ALL OWNED SCHEDULED AUTOS AUTOS BODILY INJURY (Per accident) $ NON-OWNED PROPERTY DAMAGE $ HIRED AUTOS AUTOS Per accident UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION $ $ WORKERS COMPENSATION X PER CTH- AND EMPLOYERS' LIABILITY STATUTE ER B ANY PROPRIETORIPARTNER/EXECUTIVE YIN WA-000511-02 01101/2016 01101/2017 E.L. EACH ACCIDENT $ 1,000,000 N I A OF EXCLUDED? F-1 (Mandatory in NH) EL_ DISEASE - EA EMPLOYEE $ 1,000,000 If yes, describe under DESCRIPTION OF OPERATIONS below EL DISEASE - POLICY LIMIT $ 1,000,000 DESCRIPTION OF OPERATIONS /LOCATIONS/ VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached K more space is required) RE: Oak Knoll Golf Course. The city of Ashland, Oregon, and its elected officials, officers and employees are named as Additional Insured with respect to General Liability per form CG 71 57 08 04 attached. 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 Attn: Karl Olson Purchasing Representative ACCORDANCE WITH THE POLICY PROVISIONS. 90 N. Mountain Rd Ashland, OR 97520 AUTHORIZED REPRESENTATIVE ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25 (2014101) The ACORD name and logo are registered marks of ACORD n:George Petersen Insurance Agency To:Park Avenue TurF, Inc. (15414885320) 14:20 12/28/15 GMT-08 Pg 3-4 COMMERCIAL GENERAL LIABILITY CG 71 57 08 04 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - OWNERS, LESSEES OR CONTRACTORS AUTOMATIC STATUS WHEN REQUIRED IN CONSTRUCTION CONTRACT PRIMARY AND NON-CONTRIBUTORY This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART A. Section II - Who Is An Insured is amended to 1. "Bodily injury", "property damage" or "personal include as an additional insured any person or or- and advertising injury" arising out of the ren ganization for whom you are performing opera- dering of, or the failure to render, any proles- tions when you and such person or organization sional architectural, engineering or surveying have agreed in a written contract that such person services, including: or organization be added as an additional insured a. The preparing, approving, or failing to pre- on your policy: Such person or organization is an pare or approve, maps, shop drawings, additional insured only with respect to liability for opinions, reports, surveys, field orders, "bodily injury", "property damage" or "personal and change orders or drawings and specifica- advertising injury" caused, in whole or in part, by: tions; or 1. Your acts or omissions; or b. Supervisory, inspection, architectural or 2. The acts or omissions of those acting on your engineering activities, behalf; 2. "Bodily injury" or "property damage" occurring in the performance of your ongoing operations after: for the additional insured. a. All work, including materials, parts or A person's or organization's status as an addi- equipment furnished in connection with tional insured under this endorsement ends such work, on the project (other than ser- when your operations for that additional in- vice, maintenance or repairs) to be per- sured are completed. formed by or on behalf of the additional in- No such person or organization is an addi- sured(s) at the location of the covered tional insured for liability arising out of the operations has been completed; or "products-completed operations hazard". b. That portion of "your work" out of which the injury or damage arises has been put to its B. The following is added to SECTION III - LIMITS intended use by any person or organization OF INSURANCE: other than another contractor or subcon- tractor engaged in performing operations The limits of insurance applicable to the additional for a principal as a part of the same project. insured are those specified in the written contract D. With respect to the insurance afforded to these between you and the additional insured, or the lim- additional insureds, Condition 4. Other Insur- its available under this policy, whichever are less' ance is replaced by the following: These limits are part of and not in addition to the limits of insurance under this policy. 4. Other Insurance If other valid and collectible insurance is avail- C. With respect to the insurance afforded to these able to the insured for a loss we cover under additional insureds, the following additional exclu- Coverages A or B of this Coverage Part, our sions apply: obligations are limited as follows: This insurance does not apply to: CG 71 57 08 04 Includes copyrighted material of ISO Properties, Inc., with its permission. Page 1 of 2 n:George Petersen Insurance Agency To:Park Avenue Turf, Inc. (15414885320) 14:20 12/28/15 GMT-08 Pg 4-4 CG 71 57 08 04 a. Primary Insurance When this insurance is excess over other This insurance is primary except when it is insurance, we will pay only our share of the excess as provided under part b., below. amount of the loss, if any, that exceeds the When this insurance is primary, we will not sum of: seek contribution from other Insurance (1) Tho total amount that all such other in available to the person or organization surance would pay for the loss in the shown in the Schedule of this endorsement. absence of this insurance; and b. Excess Insurance (2) The total of all deductible and self- This insurance is excess over: insured amounts under all that other in- (1) Any of the other insurance, whether surance. primary, excess, contingent or on any We will share the remaining loss, if any, with other basis: any other insurance that is not described in (a) That is Fire, Extended Coverage, this Excess Insurance provision and was not Builder's Risk, Installation Risk or bought specifically to apply in excess of the similar coverage for "your work"; Limits of Insurance shown in the Declara- (b) That is Fire insurance for premises tions of this Coverage Part. rented to you or temporarily occu- c. Method Of Sharing pied by you with permission of the owner; If all of the other insurance available to (c) That is insurance purchased by you the additional insured permits contribu- to cover your liability as a tenant for lion by equal shares, we will follow this "property damage" to premises method also. Under this approach each rented to you or temporarily occu- insurer contributes equal amounts until it pied by you with permission of the has paid its applicable limit of insurance owner, or or none of the loss remains, whichever comes first. (d) If the loss arises out of the mainte- If any of the other insurance available to nance or use of aircraft, "autos" or the additional insured does not permit watercraft to the extent not subject contribution by equal shares, we will to Exclusion g, of Section I - Cov- erage contribute by limits. Under this method, A -Bodily Injury And Prop- each insurer's share is based on the ra- erty Damage Liability do of its applicable limit of insurance to When this insurance is excess, we will have the total applicable limits of insurance of no duty under Coverages A or B to defend all insurers. the additional insured against any "suit" if any other insurer has a duty to defend the additional insured against that "suit". If no other insurer defends, we will undertake to do so, but we will be entitled to the addi- tional insured's rights against all those other insurers. All terms and conditions of this policy apply unless modified by this endorsement. Page 2 of 2 Includes copyrighted malarial of ISO Properties, Inc., with its permission. CG 71 57 08 04 rge Petersen Insurance Agency To:Park Avenue Turf, Inc. (15414885320) 14:20 12/28/15 GMT-08 Pg 1-4 Workers Comp renewal certificate attached for our insured, Park Avenue Turf, Inc. Helen Fahy Account Administrator 707-360-4331 Fax 707-546-4518 hfahy@gpins.com www.gpins.com George Petersen Insurance Agency and its Affiliates Note: The information in this E-Mail message is confidential. It is intended solely for the use of the individual(s) named -above. If VOL) are the intended recipient, be aware that your use of anv confidential, proprietary and/or personal information may be restricted by state and federal Privacy laws. 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