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Home My WebLink AboutInsurance Certificate: Jackson County (2) City County Insurance Services CERTIFICATE OF COVERAGE Rev. 717105 Agent This certificate is issued as a matter of information only and confers no rights upon the DIRECT certificate holder other than those provided in the coverage document. This certificate does not amend, extend or alter the coverage afforded by the coverage documents listed herein. Companies Affording Coverage Named Member or Participant COMPANY A - City County Insurance Services (CIS) City of Ashland COMPANY B - National Union Fire Insurance Company of Pitts, PA 20 East Main Street COMPANY C - RSUI Indemnity Ashland, OR 97520 COVERAGES This is to certify that coverage documents listed herein have been issued to the Named Member herein for the Coverage period indicated. Not withstanding any requirement, term or condition of any contract or other document with respect to which the certificate may be issued or may pertain, the coverage afforded by the coverage documents listed herein is subject to all the terms, conditions and exclusions of such coverage documents. CO Type of Coverage Certificate # Effective Expiration Limits LT Date Date A General Liability 09LASH 7/1/2009 7/1/2010 General Aggregate $15,000,000 X Commercial General Liability Each Occurrence $5,000,000 X Public Officials Liability X Employment Practices X Occurrence A Auto Liability 09LASH 7/1/2009 7/1/2010 General Aggregate None X Scheduled Autos Each Occurrence $5,000,000 X Hired Autos X Non-Owned Autos A Auto Physical Damage 09APDASH 7/1/2009 7/1/2010 X Scheduled Autos X Hired Autos X Non-Owned Autos A X Property 09PASH 7/1/2009 7/1/2010 Per Filed Values A X Boiler and Machinery 09BASH 7/1/2009 7/1/2010 Per Filed Values B X Excess Crime 09CASH 7/1/2009 7/1/2010 Per Loss $250,000 C Excess Earthquake C Excess Flood A Workers' Compensation Description: Jackson County is named as additional insured per the agreement made between Jackson County and the City of Ashland giving Ashland Fire & Rescue the exclusive right to provide ambulance service in ASA #3 effective through midnight, December 31, 2010. Certificate Holder CANCELLATION: Should any of the coverage documents herein be cancelled before the expiration date thereof, CIS will provide 30 days written notice to the certificate holder named herein, but failure to mail Jackson County such notice shall impose no obligation or liability of any kind upon CIS, its agents or representatives, or the 1005 East Main Street issuer of this certificate. Medford, OR 97504 By: /L4, V.. Date: Nov. 16, 2009 SAFETY NATIONAL CASUALTY CORPORATION EXCESS WORKERS COMPENSATION INSURANCE BINDER NAME INSURED EMPLOYER: CITY OF ASHLAND ADDRESS: 20 EAST MAIN STREET, ASHLAND, OR 97520 POLICY NUMBER: SP -3A99-OR TYPE OF INSURANCE: Specific Excess Workers' Compensation and Employers' Liability Insurance LOCATION(S): OREGON POLICY LIABILITY PERIOD: July 1, 2009 through July 1, 2010 This is to certify that the above named Insured Employer is covered by Specific Excess Workers' Compensation and Employers' Liability Insurance by the CORPORATION. Self-Insured Retention Per Occurrence for Class Code 7539 $ 650,000 Self-Insured Retention Per Occurrence for All Other $ 450,000 Maximum Limit of Indemnity Per Occurrence $ STATUTORY Employers' Liability Maximum Limit of Indemnity Per Occurrence and Aggregate $ 1,000,000 Premium Rate $0.174 per $100. of Payroll Minimum Premium for the Liability Period $ 25,483 Deposit Premium for the Payroll Reporting Period $ 25,483 This binder is effective July 1, 2009 to policy issuance and is subject to all the terms and conditions of, and shall be automatically terminated and superseded by, the Excess Workers' Compensation Agreement and Employers' Liability Insurance Agreement when issued. Issued at St. Louis, Missouri, on June 24, 2009. SAFETY NATIONAL CASUALTY CORPORATION y By: Gene R. Maier, Senior Vice President of Workers' Compensation Underwriting 1832 Schuetz Road St. Louis MO 63146-3540 314-995-5300 fax 314-995-3843 XWC 1004 00 1101 Endorsement Schedule RE: CITY OF ASHLAND Policy No: SP -3A99-OR Effective Date: 12:01 A.M. July 1, 2009 Number Title XWC 0036 01 0902 OREGON WORKERS' COMPENSATION ENDORSEMENT XWC 0098 00 0395 OREGON CANCELLATION ENDORSEMENT XWC 0236 00 0593 VOLUNTEER EXCLUSION XWC 0288 00 0908 EMPLOYERS' LIABILITY PER OCCURRENCE & AGGREGATE MAXIMUM LIMITS OF LIABILITY XWC 0467 02 1105 EMPLOYERS' LIABILITY MAXIMUM LIMIT AND AGGREGATE MAXIMUM LIMIT OF INDEMNITY XWC 0528 01 0105 SELF-INSURED RETENTION PER OCCURRENCE - ELECTRIC LIGHT OR POWER CO. XWC 1061 10 1207 POLICYHOLDER DISCLOSURE NOTICE OF TERRORISM INSURANCE COVERAGE