HomeMy WebLinkAboutInsurance Certificate: Hays Oil Company
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DATE (MM/DD/YYYY)
CERTIFICATE OF LIABILITY INSURANCE 6/22/2016
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 CONTACT Pam Wimmsr,
. NA Elliott Powell Baden and Baker Inc. PHONE (503) 227-1771 ac No : (503)274-7644
(A/C- No. 0i I 1521 S.W. Salmon Street AMAIL DDRESS: pWimmer@aPbb ' com
A
INSURERS AFFORDING COVERAGE NAIC #
Portland OR 97205-1783 INSURER A .Continental Western Insurance Co. 10804
INSURED INSURER B Great Divide Insurance Co.
RN Hays Cc, DBA: Hays Oil Company INSURER C :SAIF 36196
PO BOX 1220 INSURER D :
INSURER E :
Medford OR 97501 INSURER F :
COVERAGES CERTIFICATE NUMBER:16-17 GL, Auto, Umb a WC 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 ADOLSUOR POLICY EFF POLICY EXP LIMITS
LTR lamila POLICY NUMBER MWDD/YYYY MM/DD/YY
X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000
A CLAIMS-MADE I-X OCCUR DAMAGE TO RENTED 300, 000
PREMISES Ea occurrence $
X CPA2938039 7/1/2016 7/1/2017 MED EXP (Any one person) $ 10,000
PERSONAL & ADV INJURY $ 1,000,000
GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000
X POLICY 1 JECT PRO- F-1 LOC PRODUCTS - COMP/OP AGG $ 2,000,000
OTHER: $
AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT
Ea accident $ 1,000,000
X ANY AUTO BODILY INJURY (Per person) $
B ALL OWNED SCHEDULED
AUTOS AUTOS 8007123 7/1/2016 7/1/2017 BODILY INJURY (Per accident) $
NON-OWNED PROPER DAMAGE
X HIRED AUTOS AUTOS accident) $
$
UMBRELLA LIAR X OCCUR EACH OCCURRENCE $ 10,000,000
A X EXCESS LIAR CLAIMS-MADE AGGREGATE $ 10,000,000
DED RETENTION CUA6025552 7/1/2016 7/1/2017 $
WORKERS COMPENSATION X PER OTH_
I EMPLOYERS' LIABILITY Y / N STATUTE ER
ANY PROPRIETOR/PARTNER/EXECUTIVE E.L. EACH ACCIDENT $ 1,000,000
C OFFICER/MEMBER EXCLUDED? N/A
(Mandatory 480084 BAYS 7/1/2016 7/1/2017
in NH ) E.L. DISEASE - EA EMPLOYE $ 1,000,000
If yes, describe under
DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT $ 11000,000
A Property In Transit $100,000 Umit/Ded 1,000
DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached If more space Is required)
Re: Delivery of Fuel. Form CL CG 00 13 08 13 is attached.
CERTIFICATE HOLDER CANCELLATION
(541)488-5320
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
City of Ashland THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
90 N Mountain Ave ACCORDANCE WITH THE POLICY PROVISIONS.
Ashland, OR 97520
AUTHORIZED REPRESENTATIVE
Pam Wimmer / LJ "y-
0 1988-2014 ACORD CORPORATION. All rights reserved.
ACORD 25 (2014/01) The ACORD name and logo are registered marks of ACORD
I NSO25 (Pn i ant,
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COMMERCIAL GENERAL LIABILITY
CL CG 00 13 0813
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
GENERAL LIABILITY PLATINUM ENDORSEMENT
This endorsement modifies insurance provided under the following:
COMMERCIAL GENERAL LIABILITY COVERAGE PART
A. MEDICAL PAYMENTS
If SECTION I - COVERAGE C MEDICAL PAYMENTS is not otherwise excluded from this Coverage Part:
1. The Medical Expense Limit provided by this policy, subject to the terms of SECTION III - LIMITS OF
INSURANCE, shall be the greater of.
a. $10,000; or
b. The Medical Expense Limit shown in the Deciaratlons of this Coverage Part.
B. FIRE, LIGHTNING, EXPLOSION, SMOKE AND SPRINKLER LEAKAGE DAMAGE TO PREMISES YOU
RENT
If damage to premises rented to you under Coverage A. is not otherwise excluded from this policy, the
following applies:
1. The last paragraph of SECTION I - COVERAGE A2. Exclusions is deleted and replaced by the following:
Exclusions c. through n. do not apply to damage by fire, lightning, explosion, smoke or sprinkler leakage to
premises while rented to your or temporarily occupied by you with permission of the owner. A separate
limit of insurance applies to this coverage as described in SECTION III - LIMITS OF INSURANCE.
z Paragraph 6. of SECTION III - LIMITS OF INSURANCE Is deleted and replaced by the following:
6. Subject to Paragraph 5. above, the greater of:
a. $300,000; or
b, the Damage To Premises Rented To You Limit shown in the Declarations;
is the most we will pay under COVERAGE A for damages because of "property damage" to any one
premises, while rented to you or temporarily occupied by you with the permission of the owner.
3. Paragraph 4.b.(1)(a)(I1) Other Insurance of SECTION IV - COMMERCIAL GENERAL LIABILITY
CONDITIONS is deleted and replaced by the following:
(11) That Is Fire, Lightning, Explosion, Smoke or Sprinkler Leakage insurance for premises rented
to you or temporarily occupied by you with the permission of the owner;
4. Paragraph 9.e. of SECTION V - DEFINITIONS is deleted and replaced by the following:
a. A contract for a lease of premises. However, that portion of the contract for a lease of premises that
indemnifies any person or organization far damage by fire, lightning, explosion, smoke or sprinkler
leakage to premises while rented to you or temporarily occupied by you with permission of the owner
is not an "insured contract";
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C. LIMITED NON-OWNED WATERCRAFT
1. Paragraph g.(2) of SECTION I - COVERAGE A.2. Exclusions is deleted and replaced by the following:
A watercraft you do not own that is:
a. Less than 51 feet long; and
b. Not used to carry persons or property for a charge.
D. SUPPLEMENTARY PAYMENTS
SECTION I - SUPPLEMENTARY PAYMENTS - COVERAGES A AND B is amended as follows:
1. The limit of Insurance in paragraph 1.b. is increased from $250 to $2,500; and
2. The limit of insurance in paragraph 1.d. is increased from $250 to $500.
E. AUTOMATIC ADDITIONAL INSURED - SPECIFIED RELATIONSHIPS - PRIMARY NONCONTRIBUTORY
The following is added to Paragraph 2. of SECTION II - WHO IS AN INSURED:
a. Any person or organization described below, when you are obligated by virtue of a written contract or
agreement that such person be added as an additional insured on your policy.
When required by virtue of a written contract or agreement, coverage provided to any additional
insured will be on a primary basis and will not seek contribution from the additional insured's policy.
Only the following persons or organizations are additional insureds under this endorsement:
(1) Managers Or Lessors Of Premises. The manager or lessor of a premise leased to you, but only
with respect to liability arising from the ownership. maintenance or use of that part of the premises
leased to you and subject to the following additional exclusions:
This insurance does not apply to:
(a) Any "occurrence" which takes place after you cease to be a tenant of that premises.
(b) Structural alterations, new construction or demolition operations performed by or on behalf of
the manager or lessor.
(2) Lessor Of Leased Equipment Any person or organization from whom you lease equipment, but
only with respect to liability for "bodily injury", "property damage" or "personal and advertising
injury" caused, in whole or In part, by your maintenance, operation or use of equipment leased to
you by such person(s) or organization(s).
However, this insurance does not apply to any "occurrence" which takes place after the equipment
lease expires.
(3) Vendors. Any person or organization, but only with respect to "bodily injury" or "property damage"
arising out of "your products7 shown in the Schedule which are distributed or sold in the regular
course of the vendor's business, subject to the following additional exclusions:
a. The insurance afforded the vendor does not apply to:
1. "Bodily injury' or "property damage" for which the vendor Is obligated to pay damages by
reason of the assumption of liability in a contract or agreement. This exclusion does not
apply to liability for damages that the vendor would have in the absence of the contract or
agreement;
2. Any express warranty unauthorized by you;
3. Any physical or chemical change in the product made intentionally by the vendor
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4. Repackaging, unless unpacked solely for the purpose of inspection, demonstration,
testing, or the substitution of parts under instructions from the manufacturer, and then
repackaged in the original container,
5. Any failure to make such inspections, adjustments, tests or servicing as the vendor has
agreed to make or normally undertakes to make in the usual course of business, in
connection with the distribution or sale of the products;
6. Demonstration, Installation, servicing or repair operations, except such operations
performed at the vendors premises In connection with the sale of the product;
7. Products which, after distribution or sale by you, have been labeled or relabeled or used
as a container, part or Ingredient of any other thing or substance by or for the vendor.
b. This insurance does not apply to any insured person or organization, from whom you have
acquired such products. or any ingredient, part or container, entering into, accompanying or
containing such products.
(4) State Or Political Subdivision - Permits Or Authorizations Relating To Premises. Any state
or political subdivision, subject to the following additional provision:
This insurance applies only with respect to the following hazards for which the state or political
subdivision has issued a permit in connection with premises you own, rent, or control and to which
this insurance applies:
(a) The existence, maintenance, repair, construction, erection, or removal of advertising signs,
awnings, canopies, cellar entrances, coal holes, driveways, manholes, marquees, hoist away
openings, sidewalk vaults, street banners, or decorations and similar exposures; or
(b) The construction, erection, or removal of elevators; or
(c) The ownership, maintenance, or use of any elevators covered by this insurance.
Limits of Insurance for such additional insured are the limits in this coverage form or the limits you and such
additional insured agreed to by virtue of a contract or agreement, whichever is less. These limits are indusive
of and are not in addition to the Limits Of Insurance shown in the Declarations.
When required by virtue of a written contract or agreement, coverage provided to any additional insured
AUTOMATIC ADDITIONAL INSURED - SPECIFIED RELATIONSHIPS - PRIMARY NONCONTRIBUTORY
will be on a primary basis and will not seek contribution from the additional Insured's policy.
F. BROADENED NAMED INSURED - NEWLY ACQUIRED 180 DAYS
Paragraph 3. of SECTION 11- WHO IS AN INSURED is deleted and replaced by the following:
Any organization you newly acquire or form, other than a joint venture, and over which you maintain ownership
or majority interest of more than 50% will be a Named Insured if there is no other similar insurance available to
that organization. However:
a. Coverage under this provision is afforded only until the 180th day after you acquire or form the
organization or the end of the policy period, whichever is earlier.
b. COVERAGE A does not apply to "bodily injury" or "property damage" that occurred before you
acquired or formed the organization.
c. COVERAGE B does not apply to -personal and advertising injury" arising out of an offense committed
before you acquired or formed the organization.
G. AGGREGATE LIMITS OF INSURANCE
The General Aggregate Limit under SECTION III - LIMITS OF INSURANCE applies separately to each of
your.
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1. Projects away from premises owned by or rented to you.
2. "Locations" owned by or rented to you.
"Location" means premises involving the same or connecting lots, or premises whose connection is
interrupted only by a street, roadway, waterway or right-of-way of a railroad.
When paragraph S. Construction Project General Aggregate Limit on form CL CG 00 20 Is a part of
this policy, then paragraph G. Aggregate Limits of Insurance of this endorsement does not apply.
H. KNOWLEDGE OF OCCURRENCE
The following is added to paragraph 2. Duties In The Event Of Occurrence, Offense, Claire Or Suit of
SECTION IV - COMMERCIAL GENERAL LIABILITY CONDITIONS:
e. A report of an "occurrence", offense, claim or "suit" to:
(1) You, Nyou are an individual,
(2) A partner, if you are a partnership,
(3) An executive officer, if you are a corporation, or
(4) A manager, if you are a limited liability company;
is considered knowledge and requires you to notify us of the "occurrence", offense, claim, or "suit"
as soon as practicable.
f. We are considered on notice of an "occurrence", offense, claim or "suit" that is reported to your
Workers Compensation insurer for an event which later develops into an "occurrence", offense, claim
or "suit" for which there is coverage under this policy. However, we will only be considered on notice if
you notify us as soon as you know the claim should be addressed by this policy rather than your
Workers Compensation policy.
1. UNINTENTIONAL OMISSIONS
The following is added to paragraph 6. Representations of SECTION IV - COMMERCIAL GENERAL
LIABILITY CONDITIONS:
d. If you unintentionally fail to disclose any exposures existing at the inception date of your policy, we will
not deny coverage under this Coverage Part solely because of such failure to disclose. However, this
provision does not affect our right to collect additional premium or exercise our right of cancellation or
non-renewal.
This provision does not apply to any known injury or damage which is excluded under any other
provision of this policy.
J. MENTAL ANGUISH
Paragraph 3. of SECTION V - DEFINITIONS is deleted and replaced by the following:
3. "Bodily injury" means bodily injury, sickness or disease sustained by a person, Including mental anguish or
death resulting from any of these at any time.
K. WAIVER OF TRANSFER OF RIGHTS OF RECOVERY AGAINST OTHERS
Paragraph 8. Transfer Of Rights Of Recovery Against Others To Us of SECTION IV - COMMERCIAL
GENERAL LIABILITY CONDITIONS Is amended by the addition of the following:
We waive any right of recovery we may have because of payments we make for "bodily injury" or "property
damage" arising out of your ongoing operations or "your work" done under a contract requiring such waiver
vAth that person or organization and included In the "products-completed operations hazard".
However, our rights may only be waived prior to the "occurrence" giving rise to the injury or damage for which
we make payment under this Coverage Part. The insured must do nothing after a loss to impair our rights. At
our request, the insured will bring "suit" or transfer those rights to us and help us enforce those rights.
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Paragraph K. WAIVER OF TRANSFER OF RIGHTS OF RECOVERY AGAINST OTHERS does not apply if
another waiver of transfer of rights of recovery against others is endorsed separately to this policy.
L. OTHERINSURANCE
When Coverage applies in this General Liability Enhancement Endorsement, no other coverage or limit of
insurance in the policy applies to loss or damage insured by this coverage.
M. NON-EMPLOYMENT DISCRIMINATION LIABILITY (DEFENSE WITHIN LIMITS)
The following is added to paragraph 14. "Personal and advertising injury" SECTION V - DEFINITIONS of
COMMERCIAL GENERAL LIABILITY COVERAGE FORM:
h. Non-employment discrimination.
Non-employment discrimination means violation of a persons civil rights with respect to such persons race,
color, national origin, religion. gender, marital status, age, sexual orientation or preference, physical or mental
condition. or any other protected class or characteristic established by any federal, state or local statutes, rules
or regulations. Non-employment discrimination does not include violation of civil rights arising out of past,
present or prospective employment.
Our obligation under the Personal and Advertising Injury Liability Coverage to pay non-employment
discrimination liability damages on your behalf applies only to the amount of damages in excess of $5,000
deductible as the result of any one offense regardless of the number of persons or organizations who sustain
damages because of the offense.
The most we will pay for all damages for non-employment discrimination is $15,000 annual aggregate. No
other liability to pay sums or perform acts or services is covered.
Supplemental Payments - Coverages A and B do not apply to non-employment discrimination coverage.
N. ADDITIONAL INSURED - OWNERS, LESSEES OR CONTRACTORS OR OTHERS- AUTOMATIC,
INCLUDING PRIMARY NON-CONTRIBUTORY
1. SECTION II - WHO IS AN INSURED is amended to include as an additional insured any person or
organization for whom you are performing operations when you are obligated by virtue of a written contract
or agreement that such person or organization be added as an additional insured on your policy. Such
person or organization is an additional insured only with respect to liability for "bodily injury', "property
damage" or "personal and advertising injury" caused by your ongoing operations for the additional insured
and only to the extent that such 'bodily injury". "property damage" or "personal and advertising injury" is
caused by your negligence or the negligence of those performing operations on your behalf.
This insurance does not apply to "bodily injury", "property damage", "personal and advertising injury"
included within the "products-completed operations hazard".
This insurance does not apply to any additional insured scheduled on your policy by separate
endorsement
2. Limits of Insurance
Limits of insurance for such additional insured are the limits in this coverage form or the limits you and
such additional insured agreed to by virtue of a contract or agreement, whichever is less. These limits are
inclusive of and are not in addition to the Limits Of Insurance shown in the Declarations.
3. Exclusions
A. With respect to the insurance afforded to these additional insureds, the following additional exclusions
apply to "bodily injury", "property damage" or "personal and advertising injury" arising out of:
1. The rendering of or failure to render any professional services by you or on your behalf, but only
with respect to either or both of the following operations:
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a. Providing engineering, architectural or surveying services to others in your capacity as an
engineer, architect or surveyor, and
b. Providing, or hiring independent professionals to provide, engineering, architectural or
surveying services in connection with construction work you perform.
2. Subject to Paragraph 3. below, professional services include:
a. Preparing, approving, or failing to prepare or approve, maps, shop drawings, opinions, reports,
surveys, field orders, change orders, or drawings and specifications; and
b. Supervisory or inspection activities performed as part of any related architectural or
engineering activities.
3. Professional services do not include services within construction means, methods, techniques,
sequences and procedures employed by you or performed by or for the construction manager, its
employees or its subcontractors in connection with your ongoing operations.
B. "Bodily injury" or "property damage" occurring after:
1. All work, including materials, parts or equipment furnished in connection with such work, on the
project (other than service, maintenance or repairs) to be performed by or on behalf of the
additional insured(s) at the location of the covered operations has been completed; or
2. That portion of "your work" out of which the injury or damage arises has been put to its intended
use by any person or organization other than another contractor or subcontractor engaged in
performing operations for a principal as a part of the same project.
4. Primary Non-Contributory
When required by virtue of a written contract or agreement, coverage provided to any additional insured by
ADDITIONAL INSURED - OWNERS, LESSEES, CONTRACTORS OR OTHERS - ONGOING
OPERATIONS - AUTOINATIC, INCLUDING PRIMARY NON CONTRIBUTORY will be on a primary basis
and will not seek contribution from the additional Insured's policy.
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This is a fax from
P ib
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insurance
1521 SW Salmon St. Portland, OR 97205 503-227-1771 503-274-7644 (main fax)
Date: 06/23/2016 03:49:44 PM # of pages: 8
Fax 15414885320 Email: LJohnson@epbb.com
Subject: Renewal Certificate R W Hays Oil 16-17 Term
Comments:
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Fax
To: City of Ashland
Fax: 5414885320
From: Lori Johnson
Phone: (503)445-8433
Email: ljohnson@eppb.com
Date: 6/23/2016 3:03 PM
Subject: Renewal Certificate R W Hays Oil 16-17 Term
Memo: