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HomeMy WebLinkAboutInsurance Certificate: Pacific Mobile Structures PACIF35 OP ID: RS DATE A`coR° CERTIFICATE OF LIABILITY INSURANCE 01//1812016 18/2016 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 Phone: 360-736-7601 CONTACT Nicholson & Associates NAME: 118 W. Pine Street Fax: 360-330-0970 (AJCONN Ext : A/C No : Centralia, WA 98531-4290 E-MAIL Todd Working ADDRESS: INSURER(S) AFFORDING COVERAGE NAIC # INSURER A: American States Insurance CO. 19704 INSURED Pacific Mobile Structures Inc INSURER B: Attn: Nick Ververis P.O. Box 1404 INSURER C : Chehalis, WA 98532 INSURER D: 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 TYPE OF INSURANCE DDL B POLICY EFF POLICY EXP LTR POLICY NUMBER MM/DD/YYYY MM/DD/YYYY LIMITS GENERAL LIABILITY EACH OCCURRENCE $ COMMERCIAL GENERAL LIABILITY PREMISES Ea occurrence $ CLAIMS-MADE El OCCUR MED EXP (Any one person) $ PERSONAL & ADV INJURY $ GENERAL AGGREGATE S GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP/OP AGG $ POLICY JEC LOC $ AUTOMOBILE LIABILITY COMBINED LIMIT $ 1,000,000 A X ANY AUTO X 01C13162927 01/31/2016 01131/2017 BODILY INJURY (Per person) S ALL OWNED SCHEDULED AUTOS AUTOS BODILY INJURY (Per accident) $ NON-OWNED O E TY DAMAGE $ 1,000,00C HIREDAUTOS AUTOS $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION $ $ WORKERS COMPENSATION W C STATU- OTH- AND EMPLOYERS' LIABILITY Y I N TORY LIMITS ER ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? r- N/A E.L. EACH ACCIDENT $ i (Mandatory in NH) E.L. DISEASE -EA EMPLOYE $ If ves, describe under - DLSCRIPTION OF OPERATIONS iE- I I E.L. DISEASE - POLICY LIMIT $ DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required) City of Ashland, Oregon, and its elected officials, officers and employees. as additional insured with respects to auto liability. Coverage is primary and non contributory. Job located at 95 Winburn Way Ashland, OR 97520 CERTIFICATE HOLDER CANCELLATION CITY059 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. 20 East Main St Ashland, OR 97520 AUTHORIZED REPRESENTATIVE i ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25 (2010/05) The ACORD name and logo are registered marks of ACORD