HomeMy WebLinkAboutInsurance Certificate: Hard Working Contractor
CERTIFICATE OF LIABILITY INSURANCE D.4T 1 ~1 X20 O /DD/YY)
PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND
Any Insurance Agency CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS
123 Main St. CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE
Anywhere, OR 97000 AFFORDED BY ANY POLICIES LISTED BELOW.
INSURERS AFFORDING COVERAGE
INSURED INSURER A: Insurance Company I
INSURER B: Insurance Com any 2
Hard Working Contractor INSURER C: Insurance Company 3
456 Main St. INSURED D:
Anywhere, OR 97000 INSURER E:
COVERAGES
THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE 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 LIMIT SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS
POLICY POLICI
LTR - EXP
INSR EFFECTIN 'E
TYPE OF INSURANCE POLICY NUMBER DATE DATE LIMITS
LT
(NIM/DD/YY) (NIM/DD/YY)
A GENERAL LIABILITY EACH OCCURRENCE $1,000.000
FIRE DAMAGE (Any one tire) $100,000
® Commercial General Liability ABC 123 1/1/2010 1/1/2011 VIED EXP (Any One person) $
Claims Made ❑ Occur PERSONAL & ADV INJURY $1,000,000
❑ GENERAL AGGREGATE $2.000,000
❑ PRODUCTS- COMP/OP AGG $2,000.000
General Aggregate Limit Applies Per:
❑Policy ❑Project ❑ Loc
A AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT (Ea
accident)) $1,000,000
® ANY AUTO ABC 123 1/1/2010 I/I/2011 BODILY INJURY Per person) $
❑ ALL OWNED AUTOS BODILY INJURY (Per accident) $
❑ SCHEDULED AUTOS PROPERTY DAMAGE (Per
❑ HIRED AUTOS accident $
❑ NON-OWNED AUTOS
GARAGE LIABILITY AUTO ONLY- EA ACCIDENT $
❑ ANY AUTO OTHER THAN EA ACC $
❑ AUTO ONLY: AGG $
B EXCESS/UMBRELLA LIABILITY EACH OCCURRENCE $3,000,000
® OCCUR ❑ CLAIMS MADE XYZ789 I/1/2010 1/1/2011 AGGREGATE $3,000,000
❑ DEDUCTIBLE $
❑ RETENTION $ $
C WORKERS COMPENSATION 1234567 1/1/2010 1/1/2011 X WC STATU- OTHER $
AND EMPLOYERS' LIABILITY TORY LIMITS
E.L. EACH ACCIDENT $500,000
E.L. DISEASE - EA EMPLOYEE $500,000
E.L. DISEASE - POLICY LIMIT $500,000
OTHER
DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES/EXCLtSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS
ADDITIONAL INSURED: The State of Oregon, its officers, employees and agents as Additional Insureds but only with respect to
Contractor's activities to be performed under this Contract. Coverage shall be primary and non-contributory with any other
insurance and self-insurance.
CERTIFICATE HOLDER ADDITIONAL INSURED; INSURER LETTER CANCELLATION
STATE OF OREGON SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED
DEPARTMENT OF FORESTRY BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING INSURER,
PROCUREMENT OFFICE WILL ENDEAVOR TO MAIL WITHIN 60 DAYS WRITTEN NOTICE TO
2600 STATE STREET THE CERTIFICATE HOLDER TO THE LEFT.
SALEM, OR. 97301 AUTHORILED REPRESENTATIVE
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