HomeMy WebLinkAboutInsurance Certificate: Department of Consumer & Business Services
SfiFETV N11TIONtIL
Casualty Corporation
a DELPHI company
CERTIFICATE OF INSURANCE
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 AFFORDED BY THE POLICY LISTED BELOW.
NAME AND ADDRESS OF CERTIFICATE HOLDER:
DEPARTMENT OF CONSUMER AND BUSINESS SERVICES
ATTENTION: SELF-INSURANCE PROGRAM
WORKERS' COMPENSATION DIVISION
350 WINTER ST. NE, P.O. BOX 14480
SALEM, OR 97309-0405
This is to certify that the policy of insurance listed below has been issued to t.e insured named below and is in
force at this time. Notwithstanding any requirement, term or condition of any cd tract or any other document with
respect to which this certificate may be issued or may pertain, the instrranee offorded by the policy described
herein is subject to all the terms, exclusions and conditions of such `I0I,icy_ Sh uld any of the policy described
herein be canceled before expiration date thereof the dRP'DR,ATION willend6avor to mail sixty (60) days
written notice to the above named certificate holder, but fa4drO to gr ail such notice sl 11 impose no obligation or
liability of any kind upon the CORPORATION.
s:.
NAME INSURED EMPLOYER: CITY F`ASHLANP
ADDRESS: 20 . A MAIN STR s T "a C,46,~ ND OR 97520
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POLICY NUMBER: SIB -A99-OR
TYPE OF INSURANCE: Soeejfic Excess Workers' Compensation and Employers' Liability Insurance
LOCATION(S): 0 F~f ( N
POLICY LIABILITY PERA D- },July 2(~Q~„throu0 J 1y 1 2010
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Self-Insured Retentidn f er Occurrence fdr~;Class Code 7539 $ 650,000
Self-Insured Retention der Occurrence ~r X, 11 Other $ 450,000
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Maximum Limit of Inde nily,,Per OccurrinGe $ STATUTORY
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Employers' Liability Maxim in_,Limit of:I-rftlemnity Per Occurrence and Aggregate $ 1,000,000
SAFETY NATIONAL CASUALTY CORPORATION
By: Gene R. Maier,
Senior Vice President of Workers' Compensation Underwriting
Date: July 2, 2009
1832 Schuetz Road St. Louis MO 63146-3540 314-995-5300 fax 314-995-3843