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HomeMy WebLinkAboutInsurance Certificate: Pure Sound Entertainment/Hope Caster BOP1021592 RLI Insurance Company Renewal of Number 9025 North Lindbergh Drive Peoria, IL 61615 Form Applicable HOME BUSINESS INSURANCE POLICY ❑ Standard ® Special Policy No. BOP1021592 DECLARATIONS Named Insured and Mailing Address: Administrator Name and Mailing Address: Hope Caster Insurance Association Svcs. DBA Pure Sound Entertainment 148 S. Haskell #C 5550 S.W. Macadam, Ste. 305 Central Point, OR 97502 Portland, OR 97239 Policy Period: Insured's Brokering Agent: From 10/26/16 to 10/26/17 at 12:01 A.M.* Insurance Marketplace, Inc. Standard Time at your mailing address shown above. *Exceptions: 12:00 noon in Michigan, North Carolina, and Puerto Rico. In return for the payment of the premium, and subject to all the terms of this policy, we agree with you to provide the insurance as stated in this policy. BUSINESS DESCRIPTION Form of Business: ® Individual ❑ Joint Venture/Partnership ❑ LLC ❑ Organization (Any Other) Business description: DJ's DESCRIBED PREMISES ADDITIONAL INTEREST 148 S. Haskell #C Central Point, OR 97502 PROPERTY PREM. NO. 1 BLDG. NO. PREM. NO. 2 BLDG. NO. PREM. NO. 3 BLDG. NO. Limits of Insurance for Buildings $ N/A $ N/A $ N/A *Actual Cash Value - Buildings Option (Y/N) *Automatic Increase - Business Personal Property Limit 4% % % Business Personal Property $ 6,325 $ $ Deductible $ 250 Minimum Earned Premium $ 64 Additonal/Optional Coverages - Applicable only if an "X" Limits of Insurance is shown in the boxes below: 1. ❑ Money and Securities (Special Form only) $ Inside the Premises ❑ $ Outside the Premises 2.0 Jewelry and Watch Increased Theft Coverage 3. ® Other (specify) Additional Insured LIABILITY AND MEDICAL PAYMENTS Each paid claim for the following coverages reduces the amount of insurance we provide during the applicable annual period. Please refer to Section II - Liability in the Businessowners Coverage Form and any attached endorsements. Limits of Insurance Liability and Medical Expenses $300,000 per occurrence Medical Expenses $ 5,000 per person Damage to Premises Rented to You $ 50,000 any one premises Other Than Products/Completed Operations Aggregate $600,000 Products/Completed Operations Aggregate $600,000 FORMS AND ENDORSEMENTS Forms and Endorsements made art of this policy at time of issue: Please see reverse side. PREMIUM Policy Florida Florida Total Premium $ 257.00 HCF Surcharge $ 0.00 CPIC Surcharge $ 0.00 Annual Premium $257.00 Countersigned: By Authorized Representative THESE DECLARATIONS, TOGETHER WITH THE COVERAGE FORM(S), COMMON POLICY CONDITIONS AND FORMS, AND ENDORSEMENTS, IF ANY, ISSUED TO FORM A PART THERE OF, COMPLETE THE ABOVE NUMBERED POLICY. Includes copyrighted material of Insurance Services Office, Inc., with its permission. Copyright, Insurance Services Office, Inc., 1984, 1985 09/11/16 Insurance Association Svcs./34688 Insurance Marketplace, Inc./39607 BOP 0001 (01/10) FORMS AND ENDORSEMENTS (continued) Forms and Endorsements made part of this policy at time of issue: BP 00 03 (07/13) BUSINESSOWNERS COVERAGE FORM BOP 402 (07/02) ABUSE OR MOLESTATION EXCLUSION BOP 405 (01/10) AMENDMENT TO PROFESSIONAL LIABILITY EXCLUSION BOP 406 (07/02) INTELLECTUAL PROPERTY HAZARD EXCLUSION ENDORSEMENT BOP 410 (01/13) PERSONAL PROPERTY OFF PREMISES LIMITS ENDORSEMENT BOP 413 (07/02) EXCLUSION - WEIGHT LOSS PRODUCTS BOP 414 (01/13) EXCLUSION - MEDICAL EXPENSES COVERAGE BOP 415 (07/02) DEFINITION - VOLUNTEER WORKER BOP 426 (11/07) AUTOMATIC INCREASE - BUSINESS PERSONAL PROPERTY BOP 434 (01/13) EXCLUSION - COVERAGE EXTENSIONS BOP 441 (01/13) AGRICULTURAL OPERATIONS EXCLUSION BOP 442 (01/13) RENTAL DWELLING EXCLUSION BP 01 78 (03/15) OREGON CHANGES BP 04 17 (01/10) EMPLOYMENT-RELATED PRACTICES EXCLUSION BP 04 37 (07/02) EXCLUSION - PERSONAL AND ADVERTISING INJURY BP 05 24 (01/15) EXCLUSION OF CERTIFIED ACTS OF TERRORISM BP 05 77 (01/06) FUNGI OR BACTERIA EXCLUSION (LIABILITY) BP 05 98 (07/13) AMENDMENT OF INSURED CONTRACT DEFINITION BP 07 04 (01/06) BUSINESS LIABILITY COVERAGE - PROPERTY DAMAGE LIABILITY DEDUCTIBLE BP 14 19 (01/10) EXCLUSION - DAMAGE TO WORK PERFORMED BY SUBCONTRACTORS ON YOUR BEHALF BP 14 86 (07/13) COMMUNICABLE DISEASE EXCLUSION BP 15 05 (05/14) EXCLUSION - ACCESS OR DISCLOSURE OF CONFIDENTIAL OR PERSONAL INFORMATION BP 04 02 (07/13) ADDITIONAL INSURED - MANAGERS OR LESSORS OF PREMISES ILF 0001 (01/01) SIGNATURE PAGE Policy Number: BOP1021592 RLI Insurance Company THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - MANAGERS OR LESSORS OF PREMISES This endorsement modifies insurance provided under the following: BUSINESSOWNERS COVERAGE FORM Section II - Liability is amended as follows: This insurance does not apply to: A. The following is added to Paragraph C. Who Is An 1. Any "occurrence" that takes place after you cease Insured: to be a tenant in the premises described in the Schedule. 3. The person(s) or organization(s) shown in the Schedule is also an additional insured, but only 2. Structural alterations, new construction or demo- with respect to liability arising out of the owner- lition operations performed by or for the person(s) ship, maintenance or use of that part of the prem- or organization(s) designated in the Schedule. ises leased to you and shown in the Schedule. C. With respect to the insurance afforded to these addi- tional insureds, the following is added to Paragraph D. However: Liability And Medical Expenses Limits Of Insurance: a. The insurance afforded to such additional insured only applies to the extent permitted by If coverage provided to the additional insured is re- law; and quired by a contract or agreement, the most we will pay on behalf of the additional insured is the amount b. If coverage provided to the additional insured of insurance: is required by a contract or agreement, the insurance afforded to such additional insured 1. Required by the contract or agreement; or will not be broader than that which you are required by the contract or agreement to 2. Available under the applicable Limits Of provide for such additional insured. Insurance shown in the Declarations; B. With respect to the insurance afforded to these whichever is less. additional insureds the following additional exclusions apply: This endorsement shall not increase the applicable Limits Of Insurance shown in the Declarations. SCHEDULE Designation Of Premises (Part Leased To You): Name Of Person(s) Or Organization(s) (Additional Insured): City Of Ashland 20 East Main St Ashland, OR 97520 BP 04 02 07 13 © Insurance Services Office, Inc., 2012 Page 1 of 2 ADDITIONAL INSURED - MANAGERS OR LESSORS OF PREMISES - Contd. Additional Premium: $20 Information required to complete this Schedule, if not shown above, will be shown in the Declarations. BP 04 02 07 13 © Insurance Services Office, Inc., 2012 Page 2 of 2