HomeMy WebLinkAboutInsurance Certificate: Stephen Smith
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* OLD REPUBLIC INSURANCE COMPANY
Certificate of Insurance
This is to certify to CITY OF ASHLAND
(Certificate Holder): 51 WINDBURN WAY
ASHLAND, OR 97520
The following policy has STEPHEN C SMITH
been issued to: 1804 ANDERSON CREEK RD
TALENT, OR 97540
AIRCRAFT POLICY NO: PB 20493401 POLICY PERIOD. FROM: August 15, 2016 TO August 15, 2017
THIS COVERAGE IS EFFECTIVE 12:01 AM
INSURANCE COMPANY: OLD REPUBLIC INSURANCE COMPANY
LIABILITY COVERAGES: LIMITS OF LIABILITY
EACH PERSON EACH OCCURRENCE
Single Limit Including Passengers, $1,000,000
with Passenger liability Limited to: $200,000
DESCRIPTION OF AIRCRAFT PHYSICAL DAMAGE COVERAGE:
FAA DEDUCTIBLES
NUMBER YEAR MAKE & MODEL INSURED VALUE NOT IN-MOTION IN-MOTION
N825RV 2009 VANS RV-8 $95,000 $0 $0
THIS CERTIFICATE HOLDER IS:
Included as an Additional Insured on aircraft Liability Coverage, but only as respects operations of the Named Insured.
Provision has been made to give the Certificate Holder (30) days notice of Our cancellation of the referenced policy -
ten (10) days as a result of non-payment of premiums owed to Us. However, We assume no responsibility for the failure
to provide such notice.
This certificate is issued as a matter of information only and confers no rights upon the certificate holder.
This certificate does not amend, extend, or alter the coverage, terms, exclusions, conditions, or other provisions
afforded by the policies referenced herein nor does it constitute a contract between the issuing insurer(s),
authorized representative or producer.
Agency Name: COSTELLO INSURANCE Date: 08/03/2016
Agency Phone: ASSOCIATES,INC.
800-528-6483
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Old Republic Aerospace Representative:
1990 VAUGHN ROAD, SUITE 350, KENNESAW, GA 30144 •(770) 590-4950 -Fax: (770) 590-0599
OLD REPUBLIC INSURANCE GROUP
Costello Insurance Associates, Inc.
RVIOTION
INSUZONCE
August 12, 2016
City of Ashland
51 Windburn Wav
Ashland, OR 97520
INSURANCE SHOWING
ADDITIONAL INSURED (LIABILITY) INTEREST
Owner: Stephen C Smith
Property: Aviation N825RV
Company: Old Republic
Policy No.: P22049340_
Effective Date: August 15, 2016
Term: 1 Year
The enclosure shown below protects your interest in the above property in
accordance with the policy provisions. Please advise if any corrections are
necessary.
Enclosed: insurance certificate with addi Tonal insured wording
Best Regards,
Riley Clark
J
P. O. BOX 28280 / 428 E. SOUTHERN AVENUE / TEMPE, AZ. 85285-8280
TEL: 480-968-7746 / 800-528-6483 / FAX: 480-967-3828 / insure@aviationi.com