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Home My WebLink About1999-035 Grant -Mediation Works CITY OF ASHLAND FINANCIAL ASSISTANCE AWARD CONTRACT CITY: CITY OF ASHLAND 20 E Main Street Ashland OR 97520 (541) 488-5300 FAX: (541) 488-5311 GRANTEE: Address: Telephone: Mediation Works 33 North Central, Ste. 306 Medford, OR 97501 541-770-2468 Date of this agreement: July 1, 1999 Amount of grant: $4,260 Budget subcommittee: Social Services Contract made the date specified above between the City of Ashland and Grantee named above. RECITAL: City has reviewed Grantee's application for a grant and has determined that the request merits funding and the purpose for which the grant is awarded serves a public purpose. City and Grantee agree: 1. Amount of Grant. Subject to the terms and conditions of this contract and in reliance upon Grantee's approved application, the City agrees to provide funds in the amount specified above. 2. Use of Grant Funds. The use of grant funds are expressly limited to the activities in the grant application with modifications, if any, made by the budget subcommittee designated above. 3. Unexpended Funds. Any grant funds held by the Grantee remaining after the purpose for which the grant is awarded or this contract is terminated shall be returned to the City within 30 days of completion or termination. 4. Financial Records and Inspection. Grantee shall maintain a complete set of books and records relating to the purpose for which the grant was awarded in accordance with generally accepted accounting principles. Grantee gives the City and any authorized representative of the City access to and the right to examine all books, records, papers or documents relating to the use of grant funds. 5. Default. If Grantee fails to perform or observe any of the covenants or agreements contained in this contract or fails to expend the grant funds or enter into binding legal agreements to expend the grant funds within twelve months of the date of this contract, the City, by written notice of default to the Grantee, may terminate the whole or any part of this contract and may pursue any remedies available at law or in equity. Such remedies may include, but are not limited to, termination of the contract, stop payment on or return of the grant funds, payment of interest earned on grant funds or declaration of ineligibility for the receipt of future grant awards. 6. Amendments. The terms of this contract will not be waived, altered, modified, supplemented, or amended in any manner except by written instrument signed by the parties. Such written modification will be made a part of this contract and subject to all other contract provisions. 7. Indemnity. Grantee agrees to defend, indemnify and save City, its officers, employees and agents harmless from any and all losses, claims, actions, costs, expenses, judgments, subrogations, or other damages resulting from injury to any person (including injury resulting in death,) or damage (including loss or destruction) to property, of whatsoever nature arising out of or incident to the performance of this agreement by Grantee (including but not limited to, Grantee's employees, agents, and others designated by Grantee to perform work or services attendant to this agreement). Grantee shall not be held responsible for damages caused by the negligence of City. 8. Insurance. Grantee shall, at its own expense, at all times for twelve months from the date of this agreement, maintain in force a comprehensive general liability policy including coverage for contractual liability for obligations assumed under this Contract, blanket contractual liability, products and completed operations, and owner's and contractor's protective insurance. The liability under each policy shall be a minimum of $500,000 per occurrence (combined single limit for bodily injury and property damage claims) or $500,000 per occurrence for bodily injury and $100,000 per occurrence for property damage. Liability coverage shall be provided on an "occurrence" not "claims" basis. The City of Ashland, its officers, employees and agents shall be named as additional insureds. Certificates of insurance acceptable to the City shall be filed with City's Risk Manager prior to the expenditure of any grant funds. 9. Merger. This contract constitutes the entire agreement between the parties. There are no understandings, agreements or representations, oral or written, not specified in this contract regarding this contract. Grantee, by the signature below of its authorized representative, acknowledges that it has read this contract, understands it, and agrees to be bound by its terms and conditions. GRANTEE Its CITY OF ASHLAND BY ~c/tor of Financ~'/t"""~ BY Its Content review by: Department Head Form review by: ~ (City Attorney) Coding: (for City use only) PAGE 2-GRANT AGREEMENT ~." ,... STA T~ F~R~,' INSURANCE COMPANIES A Slate Farm Fire and Casualty ComplLQl( ,. PO Box 5000 Dupont, WA 98327-5000 _ RENEWAL CERTIFICATE '2 POLICY NUMBER o 97-BG-9222-6 I I BUSINESS-OFFICE MAR 31 2001 TO MAR 31 2002 I DATE DUE I MAR 31 2001 PLEASE PAY THIS AMOUNT $175.00 V-2024-F472 F U 3 MEDIATION WORKS, A COMMUNITY DISPUTE RESOLUTION CENTER 33 N CENTRAL AVE STE 306 MEDFORD OR 97501-5939 Coverages and Limits Section I A Buildings B Business Personal Property C LDSS of Income Excluded 22,200 Actual Loss 11,1.,1,"1,1,1,11111",11,1,1,1.1""11,1.1,,1,,1,,,,11,,11.1 Deductlbles . Section I Basic Other deductibles may apply - refer to policy 500 Location: 33 N CENTRAL AV STE 306 MEDFORD OR Section II L Business Liability M Medical Payments Gen Aggregate (Other than PCO) Products-Completed Operations (PCO Aggregate) $1,000,000 5,000 2~000,000 t.xcl uded Add Ins-II: RUSS DALE PROPERTIES Add Ins-II: CITY OF ASHLAND ITS OFFICERS, Forms, Options, and Endorsements Special Form 3 Amendatory End Debris Removal Endorsement Policy Endorsement ProductslOperations Liab Excl Personal Injury Exclusion End Additional Insured Endorsement Glass Deductible Change Designated Premises Limitation Advertising Injury Excl End Additional Insured Amendatory Collapse FP-6103 FE-6237.1 FE-6451 FE-6464 FE-6312 FE-6346 FE-6494 FE-6538.1 FE-6351 FE-6345 FE-6324 FE-6551 Annual Premium Forms, Opts, & Endrsmnt Bus Liability - Cov L Amount Due $113.00 40.00 22.00 $175.00 Premium Reductions Your premium has already been reduced by the following: Renewal Year Discount Yrs in Business Discount Claim Record Discount Cov. A - Inflation Index: N/A Cov. B - Consumer Price: 174.1 (g@~W ~A 4Q) ~/O~ /0/ #.~/- '-"-rOO Tk6 fr.r-.1!ett~uS.s'e/'1Ie fPJ.,.. ~.Jent rAURA J BIXBY INS AGENCY INC Telephone (541) 482-2461 See reverse side for important information, Please keep this part for your record. Prepared FEB 09 2001 & STATE FARM INSURANCE COMPANIES State Farm Fire and Casualty Comr "v PO Box 5000 Dupont, WA 98327-5000 RENEWAL CERTIFICATEV 12 POLICY NUMBER 11 10 97-BG-9222-6 BUSINESS-OFFICE MAR 31 2000 TO MAR 31 2001 DATE DUE PLEASE PAY THIS AMOUNT PAID BY SPECIFIED PARTY T- 2024-F472 F U 3 CITY OF ASHLAND ITS OFFICERS, EMPLOYEES 8 AGENTS 20 E MAIN ST ASHLAND OR 97520-1849 Coverages and Limits Section I A Buildings B Business Personal Property C Loss of Income Excluded 21 400 Actual Loss 11,1.,1",1.1,1",1,111"",,111,,1,,1,.11,1.,1.1,,1,1,,1,,,II Deductibles . Section I Basic Other deductibles may apply - refer to policy 500 Insured: MEDIATION WORKS, A COMMUNITY DISPUTE RESOLUTION CENTER Location: 33 [\j CENTRAL A V STE 306 MEDFORD OR Section II L Business Liability M Medical Payments Gen Aggregate (Other than PCO) Products-Completed Operations (PCO Aggregate) $1,000,000 5,000 2,!.000,000 txcluded Add Ins-II: RUSS DALE PROPERTIES Add Ins-II: CITY OF ASHLAND ITS OFFICERS, Forms, Options, and Endorsements Special Form 3 Amendatory End Debris Removal Endorsement Policy Endorsement I Products/Operations Liab Excl Personal Injury Exclusion End Additional Insured Endorsement Glass Deductible Change Designated Premises Limitation Advertising Injury Excl End Additional Insured Amendatory Collapse FP-6103 FE-6237.1 FE-6451 FE-6464 FE-6312 FE-6346 FE-6494 FE-6538.1 FE-6351 FE-6345 FE-6324 FE-6551 Annual Premium Forms, Opts, & Endrsmnt Bus Liability - Cov L Total Amount $111,00 42,00 22,00 $175.00 Premium Reductions Your premium has already been reduced by the following: Renewal Year Discount Yrs in Business Discount Claim Record Discount Cov. A - Inflation Index: N/A Cov. B - Consumer Price: 168.3 Tluvrfs b-- tUtlr.?-aS'~ fIb!... Agent t..A.URA J BIXBY INS AGENCY INC Telephone (541) 482-2461 See reverse side for important information. Please keep this part for your record. Prepared FEB 11 2000 .. STATE FARM INSURANCE COMPANIES State Farm Fire and Casualty Camp' " 4600 25th Avenue North East Salem, OR 97313-1000 \ l j RENEWAL CERTIFICATE 12 POLICY NUMBER 11 10 97 -BG-9222-6 I I BUSINESS-OFFICE MAR 311999 TO MAR 312000 I DATE DUE PLEASE PAY THIS AMOUNT I PAID BY SPECIFIED PARTY S-2024-F472 F U 3 ~~~rO~~E~S~L~~~NfIS OFFICERS, 20 E MAIN ST ASHLAND OR 97520-1849 Coverages and Limits Section I A Buildings B Business Personal Property C Loss of Income Excluded 20,800 Actual Loss 11,1"1",1,1,11111,111",,,,111,,1,,1,,11,1,,1,1,,1,1,,1,,,11 Deductibles - Section I Basic Other deductibles may apply - refer to policy 500 Insured: MEDIATION WORKS, A COMMUNITY DISPUTE RESOLUTION CENTER Location: 33 N CENTRAL AV STE 306 MEDFORD OR Section II L Business Liability M Medical Payments Gen Aggregate (Other than PCO) Products-CDmpleted Operations (PCO Aggregate) $1,000,000 5,000 2~000,000 t.xcluded Add Ins-I\: RUSS DALE PROPERTIES Add Ins-I\: CITY OF ASHLAND ITS OFFICERS, Forms, Options, and Endorsements Special Form 3 Amendatory End Debris Removal Endorsement Policy Endorsement Products/Operations Liab Excl Personal Injury Exclusion End AdditiDnallnsured Endorsement Glass Deductible Change Designated Premises Limitation Advertising Injury Excl End Additional Insured FP-6103 FE-6237.1 FE-6451 FE-6464 FE-6312 FE-6346 FE-6494 FE-6538.1 FE-6351 FE-6345 FE-6324 Annual Premium Forms, Opts, & Endrsmnt Bus Liability - Cov L Total Amount $108.00 44.00 23.00 $175.00 Premium Reductions Your premium has already been reduced by the following: Renewal Year Discount Yrs in Business Discount Cov. A. Inflation Index: N/A COV. B - Consumer Price: 164.0 ~~~<<J'~p.. Agent l[AURA 5 BIXBY INS AGENCY INC Telephone (541) 482-2461 See reverse side for important information_ Please keep this part for your record. Prepared FEB 05 1999 --,~,~..- _.-- CITY OF ASHLAND CITY HALL ASHLAND, OREGON 97520 June 29, 1999 Maureen Sweeney Mediation Works 33 North Central, Ste, 306 Medford, OR 97501 Dear Ms. Sweeney: The City of Ashland Budget for the 1999-2000 fiscal year was approved by the City Council on June 15. Your grant of $4,260 is included in this budget. The payment will be made following the City's receipt of the enclosed contract with signature. The City requires grant recipients to supply a certificate of insurance indicating liability coverage of not less than $500,000 per occurrence. The City, its officers, and employees must be named as additional insureds. Please sign the enclosed contract and return it to the City as soon as possible. Once the signed contract is on file, the payment schedule can be implemented. Sincerely, ;;fYlu~ ~~ner Director of Finance kg Enclosure G:\BUDGE1\Social ServicesIMail Merge formslgranteeijr.doc Policy Number 97-BG-9222-6 DECLARATIONS PAGE AMENDED MAR 31 1998 STATE FARM FIRE AND CASUALTY COMPANY 4600 25TH AV N EAST, SALEM OR 97313-1000 A STOCK COMPANY WITH HOME OFFICES IN BLOOMINGTON, ILLINOIS $r"'lIIA." A .."u....a . 1732-F472 S Named Insured and Mailing Address COMMUNITY DISPUTE RESOLUTION CENTER 33 N CENTRAL AVE STE 306 MEDFORD OR 97501-5939 Cov A -Inflation Coverage Index: N/A BUSINESS POLICY - SPECIAL FORM 3 Cov B - Consumer Pricelndex: 161.6 AUTOMATIC RENEWAL - If the POLICY PERIOD is shown as 12 MONTHS, this policy will be renewed automatically subject to the premiums, rules and forms in effect for each succeedinQ policy period. If this policy is terminated, we will give you and the Mortgagee/Lienholder written notice in compliance wilH the policy provisions or as required by law. Policy Period: 12 Months The policy period begins and ends at 12:01 am standard time at the Effective Date: MAR 31 1998 premises location. Expiration Date: MAR 31 1999 Named Insured: Corporation Location of Covered Premises: 33 N CENTRAL AV STE 306 MEDFORD OR 97501-5939 Your policy is amended MAR 31 1998 ADDL INSURED NAME & ADDRESS ADDED ENDORSEMENT FE-6324 ADDED Coverages & Property Section I A Buildings B Business Personal Property C Loss of Income Limits of Insurance Uccupancy: Uttlce Excluded $ 20,400 $ Actual LDSS Section II L Business Liability M Medical Payments Products-Completed Operations (PCO) Aggregate General Aggregate (Other Than PCO) $ 1,000,000 $ 5,000 Excluded $ 2,000,000 Deductibles - Section I $ 250 Basic Forms, Options, and Endorsements Special Form 3 *Additionallnsured Amendatory End Debris Removal Endorsement POlicy Endorsement Products/Operations Liab Excl Personal Injury Exclusion End * New Form Attached FP-6103 FE-6324 FE-6237.1 FE-6451 FE-6464 FE-6312 FE-6346 In case of loss under this policy, the deductible will be applied to each occurrence and will be deducted from the amount of the loss. Other deductibles may apply - refer to policy. Endorsement Premium Increase $ 30.00 Continued on Reverse Side of Page OTHER LIMITS AND EXCLUSIONS MAY APPLY - REFER TO YOUR POLICY Countersigned_ ~'-'f!7 i ~~URIE ~~J n .I ~ (541) 482-2461 Prepared MAY 041998 FP-8030.2C 06/1993 Your policy consists of this page, any endorsements and the policy form. PLEASE KEEP THESE TOGETHER. ACID /;;2. /9CJj I Agent (o1f2172b) LS Policy No. 97-BG-9222-6 FE-6324 (7/68) irATi .AIM A ADDITIONAL INSURED ENDORSEMENT Owners, Lessees or Contractors (Form B) INIU.ANU . Policy No.: 97-BG-9222-6 Named Insured: COMMUNITY DISPUTE RESOLUTION CENTER Name of Person or Organization: CITY OF ASHLAND ITS OFFICERS, EMPLOYEES & AGENTS 20 E MAIN ST ASHLAND OR 97520-1849 WHO IS AN INSURED, under SECTION II DESIGNATION OF INSURED, is amended to include as an insured the person or organization shown above, but only with respect to liability arising out of your work fDr that insured by or for you. FE-6324 (7/88) Printed in U.S.A. CITY OF ASHLAND FINANCIAL ASSISTANCE AWARD CONTRACT CITY: CITY OF ASHLAND 20 E Main Street Ashland OR 97520 (541) 488-5300 FAX: 541 488-5311 GRANTEE: Community Dispute Resolution Center Address: 33 N Central Ave Ste 306 Medford OR 97501 Tele hone: 541 770-2468 Date of this a reement: June 19, 1998 1. Amount of rant: $4,140 Contract made the date specified above between the City of Ashland and Grantee named above, RECITAL: City has reviewed Grantee's application for a grant and has determined that the request merits funding and the purpose for which the grant is awarded serves a public purpose. City and Grantee agree: 1. Amount of Grant. Subject to the terms and conditions of this contract and in reliance upon Grantee's approved application, the City agrees to provide funds in the amount specified above. 2. Use of Grant Funds. The use of grant funds are expressly limited to the activities in the grant application with modifications, if any, made by the budget subcommittee designated above. 3. Unexpended Funds. Any grant funds held by the Grantee remaining after the purpose for which the grant is awarded or this contract is terminated shall be returned to the City within 30 days of completion or termination. 4. Financial Records and Inspection, Grantee shall maintain a complete set of books and records relating to the purpose for which the grant was awarded in accordance with generally accepted accounting principles. Grantee gives the City and any authorized representative of the City access to and the right to examine all books, records, papers or documents relating to the use of grant funds. 5. Default. If Grantee fails to perform or observe any of the covenants or agreements contained in this contract or fails to expend the grant funds or enter into binding legal agreements to expend the grant funds within twelve months of the date of this contract, the City, by written notice of default to the Grantee, may terminate the whole or any part of this contract and may pursue any remedies available at law or in equity. Such remedies may include, but are not limited to, termination of the contract, stop payment on or return of the grant funds, payment of interest earned on grant funds or declaration of ineligibility for the receipt of future grant awards. 6. Amendments. The terms of this contract will not be waived, altered, modified, supplemented, or amended in any manner except by written instrument signed by the parties. Such written modification will be made a part of this contract and subject to all other contract provisions. 7. Indemnity. Grantee agrees to defend, indemnify and save City, its officers, employees and agents harmless from any and all losses, claims, actions, costs, expenses, judgments, subrogations, or other damages resulting from injury to any person (including injury resulting in death,) or damage (including loss or destruction) to property, of whatsoever nature arising out of or incident to the performance of this agreement by Grantee (including but not limited to, Grantee's employees, agents, and others designated by Grantee to perform work or services attendant to this agreement). Grantee shall not be held responsible for damages caused by the negligence of City. 8. Insurance. Grantee shall, at its own expense, at all times for twelve months from the date of this agreement, maintain in force a comprehensive general liability policy including coverage for contractual liability for obligations assumed under this Contract, blanket contractual liability, products and completed operations, and owner's and contractor's protective insurance. The liability under each policy shall be a minimum of $500,000 per occurrence (combined single limit for bodily injury and property damage claims) or $500,000 per occurrence for bodily injury and $100,000 per occurrence for property damage. Liability coverage shall be provided on an "occurrence" not "claims" basis, The City of Ashland, its officers, employees and agents shall be named as additional insureds. Certificates of insurance acceptable to the City shall be filed with City's Risk Manager prior to the expenditure of any grant funds. 9. Merger. This contract constitutes the entire agreement between the parties. There are no understandings, agreements or representations, oral or written, not specified in this contract regarding this contract. Grantee, by the signature below of its authorized representative, acknowledges that it has read this contract, understands it, and agrees to be bound by its terms and conditions. GRANTEE BY ,1)1~}--C' _ . "-- Its f.1--€ C u.. \\w b ( p( f-ov ~:~1)j:H1J CITY OF ASHLAND BY jrl/~~~ irect010 Finance Content review bY:~ epartment Head ---. Form review by: (City Attorney) Coding: (for City use only) PAGE 2-GRANT AGREEMENT (GIBUDGET\Social ServiceslSS Grant Contracts 199B.wpd) CITY OF ASHLAND FINANCIAL ASSISTANCE AWARD CONTRACT CITY: CITY OF ASHLAND 20 E Main Street Ashland OR 97520 (541) 488-5300 FAX: 541 488-5311 Date of this a reement: Jul 1, 1997 1, Amount of rant: $4,000 GRANTEE: Community Dispute Resolution Center Address: 33 N Central Ave Ste 306 Medford OR 97501 Tele hone: 541 770-2468 Contract made the date specified above between the City of Ashland and Grantee named above. RECITAL: City has reviewed Grantee's application for a grant and has determined that the request merits funding and the purpose for which the grant is awarded serves a public purpose. City and Grantee agree: 1. Amount of Grant. Subject to the terms and conditions of this contract and in reliance upon Grantee's approved application, the City agrees to provide funds in the amount specified above. 2. Use of Grant Funds. The use of grant funds are expressly limited to the activities in the grant application with modifications, if any, made by the budget subcommittee designated above. 3. Unexpended Funds. Any grant funds held by the Grantee remaining after the purpose for which the grant is awarded or this contract is terminated shall be returned to the City within 30 days of completion or termination. 4. Financial Records and Inspection. Grantee shall maintain a complete set of books and records relating to the purpose for which the grant was awarded in accordance with generally accepted accounting principles. Grantee gives the City and any authorized representative of the City access to and the right to examine all books, records, papers or documents relating to the use of grant funds. 5. Default, If Grantee fails to perform or observe any of the covenants or agreements contained in this contract or fails to expend the grant funds or enter into binding legal agreements to expend the grant funds within twelve months of the date of this contract, the City, by written notice of default to the Grantee, may terminate the whole or any part of this contract and may pursue any remedies available at law or in equity. Such remedies may include, but are not limited to, termination of the contract, stop payment on or return of the grant funds, payment of interest earned on grant funds or declaration of ineligibility for the receipt of future grant awards, 6. Amendments, The terms of this contract will not be waived, altered, modified, supplemented, or amended in any manner except by written instrument signed by the parties. Such written modification will be made a part of this contract and subject to all other contract provisions. 7. Indemnity. Grantee agrees to defend, indemnify and save City, its officers, employees and agents harmless from any and all losses, claims, actions, costs, expenses, judgments, subrogations, or other damages resulting from injury to any person (including injury resulting in death,) or damage (including loss or destruction) to property, of whatsoever nature arising out of or incident to the performance of this agreement by Grantee (including but not limited to, Grantee's employees, agents, and others designated by Grantee to perform work or services attendant to this agreement). Grantee shall not be held responsible for damages caused by the negligence of City, 8. Insurance. Grantee shall, at its own expense, at all times for twelve months from the date of this agreement, maintain in force a comprehensive general liability policy including coverage for contractual liability for obligations assumed under this Contract, blanket contractual liability, products and completed operations, and owner's and contractor's protective insurance, The liability under each policy shall be a minimum of $500,000 per occurrence (combined single limit for bodily injury and property damage claims) or $500,000 per occurrence for bodily injury and $100,000 per occurrence for property damage. Liability coverage shall be provided on an "occurrence" not "claims" basis. The City of Ashland, its officers, employees and agents shall be named as additional insureds, Certificates of insurance acceptable to the City shall be filed with City's Risk Manager prior to the expenditure of any grant funds, 9. Merger. This contract constitutes the entire agreement between the parties. There are no understandings, agreements or representations, oral or written, not specified in this contract regarding this contract. Grantee, by the signature below of its authorized representative, acknowledges that it has read this contract, understands it, and agrees to be bound by its terms and conditions. GRANTEE BY~' Its -e. <>C- lIro?o-k,,-- ~i~~ CITY OF ASHLAND - BY ~.(( /U-/_~f~ D' ec 0 of Finance Content review by: ~. IDepartment Head Form review by: v---- (City Attorney) Coding: (for City use only) PAGE 2-GRANT AGREEMENT (g:\budgetlsocialselssgrant.frm) This is to certify that A. CERTIFICATE 0' INSURANCE ~ QSTATE FAAMFIRE AND CASUALTVCOMPANY, Bloomil'19ton.lllinois o STATE FARM GENERAL INSURANCE COMPANY. Bloomington, lHinois has in force for ~"'f"'\m 'nni't--v 1")1 ~(ll1t-.. 33'T '~"'1l;:r~l O\"Q '{:""'l<::'r\ 1 ;''''''1 t,",n ',"''lnt"4?ir Name of Policyholder "'"it", -'n6 Add....s of Policyholder MQ,l f'),t"3 .~" 97""01 location of operations the following coverages for the periods and limits indicated below. POLICY NUMBER TYPE OF INSURAHC.E POLlCY PeRIOD " L1MITSOFLIABtLITY '(efUexp.) 97 "~ ':'222 6 Q Comprehensive 3/ U/97 3/31/98 Qoual.LimitS f()!: BODILY INJURY J'...' General Liability Each Occurrence $ 1 000 'lor} 0 Manufacturers' and Aggregate $ 2 (ll) ')0 r")(}') Contractors' Liability 0 Owners', Landlords'and PROPERTY DAMAGE . Tenants' Liability , Each -Occurrence $ The above insurance includes 0 (applicable if indicated by igJ ) PRODUCTS-COMPLETED OPERATIONS Aggregate' $ ~ OWNERS' OR CONTRACTORS' PROTECTIVE LIABILITY o Combined Single Umitfor: G CONTRACTUAL LIABILITY BODILY INJURY AND Ii.] BROAD FORM PROPERTY DAMAGE PROPERTY DAMAGE liJ BROAD FORM COMPREHENSIVE GENERAL LIABILITY Each Occurrence $ POLICY NUdER TYPE OF INSURANCE POLlCV PERIOD Aggregate $ (efl./exp.) CONTRACTUAL LIABILITY LIMITS (U diU",,,,,t than above) . BODILY INJURY 0 Each Occurrence $ PROPERTY DAMAGE 0 Each OccurrenCEli $ , 0 Aggregate $ , , , . o Combined Single Limit lor: . EXCESS .L1ABILITY BODiLY INJURY AND . 0 PROPERTY DAMAGE Ulnbrella 0 Other Each Occurrence $ ...-..,.,.-.~-,--...., -----,..' f--'-' . Aggr~g~_t! $ '- , .., ..._,~ - . , Part 1 STATUTORY Workers Compensation Part 2 BODILY INJURY 0 and Employers Each Accident $ Liabilily Olsease-Each Employee $ Di5~e-Pollcy limit $ .Aggr-egate -not'applicable if Owners', Landlo''d~' and Tenants' 'Liability Insurance excludes..structuralaU-erations, new,constructfonorde-molition, THE;CERTlFlCATE OF INSURANCE IS N,OTACQIITRIlCT OF INSURANCE~D.ITHER' AffiRMATIVELY NOR NEGATIVELY AMENDS, EXTENDS OR Ai;. T1!RSTHE COVERAGEAPPflOVEO IV AfCY POLICY DESCRIBED HEREIN. NAM'E AND AoefIES5 OF PARTY TO WHOM CERTIFICATE IS ISSUED r ~ ~ity of ~shl~n~ Tts 0~~icer~ '1nc1 r'llploY'3c;; 1it." Ie'll J "\"'~ '11a'r!"1 ....,,~t! ~ 7~. ~ n f--.~ 'T'Lll "rnc-r 11 ]C,97 ,558)F6-994.9 Rev. 1-86 Printed in U.S.A.