HomeMy WebLinkAboutInsurance Certificate: Oregon Bicycle Racing Association (2)
DATE (MM/DD/YYYY)
Certificate of General Liability & Accident Medical Insurance 04/09/2009
PRODUCER Phone: (800) 747-9573 Fax: (303) 422-1276 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
The Camp Team ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
7615 W. 38Th Avenue, Unit B-109 HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
Wheat Ridge CO 80033 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
INSURERS AFFORDING COVERAGE NAIC #
INSURED INSURER A: Capitol Speciality Ins. Corp
Oregon Bicycle Racing Association INSURER B: StarNet Insurance Company
P.O. Box 5773 INSURER C:
Salem, OR 97304
INSURER D:
INSURER E:
COVERAGES
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. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
INSR ADD'_ TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATION LIMITS
LTR I SRD DATE (MM/DD/YY) DATE (MM/DD/YY)
GENERAL LIABILITY CS00217968 01/16/2009 01/16/2010 EACH OCCURRENCE 1,000,000
X DAMAGE TO RENTED 100,000
COMMERCIAL GENERAL LIABILITY REMISES (Ea occurrence)
I CLAIMS MADE X OCCUR ED. EXP (Spectator Only) 5,000
A X INC ATHLETIC PARTICIPANTS PERSONAL s ADV INJURY 1,000,000
GENERAL AGGREGATE 2,000,000
PRODUCTS-COMP/OP AGG. 1,000,000
BODILY INJURY 0
X DEDUCTIBLES PROPERTY DAMAGE 500
AUTOMOBILE LIABILITY CS00217968 01/16/2009 01/16/2010 COMBINED SINGLE LIMIT 1,000,000
ANY AUTO Ea accident)
ALL OWNED AU `OS BODILY INJURY
SCHEDULED AUTOS Per person)
A
X HIRED AUTOS
BODILY INJURY
X NON-OWNED AUTOS Per accident
PROPERTY DAMAGE
Per accident)
ACCIDENT MEDICAL MAXIMUM MEDICAL BENEFIT 10,000
PER CLAIM
X ACCIDENTAL DEATH & 2,500
Excess To Primary Health Ins. DISMEMBERMENT
B Policy will not cover primary health To Be Determined 01/16/2009 01/16/2010
insurance deduct tiles, co-pays,
X program limits, or out of network care.
It injured party does not have primary DEDUCTIBLE PER CLAIM 1 ,000
care, excess coverage becomes
primary.
EXCESS / UMBRELLA LIABILITY EACH OCCURRENCE
OCCUR CLAIMS MADE AGGREGATE
DEDUCTIBLE
RETENTION $
OTHER:
DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES/EXCLUSIONS ADDED BY ENDORSEMENTS/SPECIAL PROVISIONS
Bicycle Racing / The Ashland 12 Mile Super D - MTB - Super D/ USA
Additional Insured(s): US Government c/o Ashland Ranger Station, The City of Ashland, its, agents and employees, Breakaway Events, Ernst Holdings,
LLC, Thomas Rollins, Ken and Margaret Palen, Mt. Ashland Ski Resort, All participants, staff and facilities as scheduled with the company are added as
additional insured in regards to the operations of the insured.
CERTIFICATE HOLDER CANCELLATION
12 Mile Super D SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION
Marla (Tlta) Soriano DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 30 DAYS WRITTEN NOTICE
280 N. 2nd St. TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL IMPOSE
NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR
Ashland, OR 97520 REPRESENTATIVES.
AUTHORIZED REPRESENTATIVE
attention:
Bob Leid