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HomeMy WebLinkAboutInsurance Certificate: Jackson County SART 1 Ll DATE (MM/DD/YYYY) ACORL7~ CERTIFICATE OF LIABILITY INSURANCE FTHIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE H LDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER Phone. 503-365-7001 Fax: 503-365-7354 CONTACT REINHOLDT & O'HARRA NAME: MID VALLEY GENERAL AGENCY LLC PHONE FAX 1541-488-4458 (A/C, No, Ext) (541) 482-1921 I(A/C, No): 4305 RIVER ROAD N E-MAIL ADDRESS: MKLAICH@REINHOLDTINS.COM KEIZER OR 97303 PRODUCER 25108 CUSTOMER ID _ INSURER(S) AFFORDING COVERAGE NAIC # INSURED INSURERA : SHAND, MORAHAN & CO., INC. 35378 JACKSON COUNTY SART C/O MOEN, SUSAN INSURER B 43 MORNING LIGHT DRIVE INSURER C ASHLAND OR 97520 INSURER D. INSURER E INSURER F COVERAGES CERTIFICATE NUMBER: 49673 REVISION NUMBER: THIS IS TO CERTIFY THAT 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, FXCI I JSIONS AND r()NnITI(')NS OF SUCH POI ICIFR I IMITS SHOWN MAY HAVE BEEN RFF)UrFn BY PAID (1.1 AIMS I TSRR AIDDL' SUBR POLICY EFF POLICY EXP LIMITS TYPE OF INSURANCE R WVD POLICY NUMBER (MM/Dom Y) jMM/DD/YYYY) - - A GENERAL unalurY SM-881752 08/17111 08/17/12 EACH OCCURRENCE $ 1,000,000 X COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED $ 50,000 PREMISES (Ea occurence) CLAIMS-MADE X OCCUR MED. EXP (Any one person) $ 1,000 PERSONAL & ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 3,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP/OP AGG $ INCLUDED ~ POLICY PRO- LOC $ JECT AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ (Ea accident) ANY AUTO - - BODILY INJURY (Per person) $ ALL OWNED AUTOS - - - - BODILY INJURY (Per accident) $ SCHEDULED AUTOS - - PROPERTY DAMAGE HIRED AUTOS (Per accident) $ NON-OWNED AUTOS $ UMBRELLA LIAR OCCUR EACH OCCURRENCE $ - EXCESS LIAB CLAIMS-MADE AGGREGATE $ DEDUCTIBLE $ RETENTION $ $ WORKERS COMPENSATION WC STATU OTH AND ZNIFLOYEPS' LIABILITY YIN TORY LIMITS. - ER_ ANY PROPRIETOR/PARTNER/EXECUTIVE E.L. EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? N/A (Mandatory in NH) E.L. DISEASE-EA EMPLOYEE $ If yes, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required) SEE SUPPLEMENTAL CERTIFICATE INFORMATION CERTIFICATE HOLDER CANCELLATION CITY OF ASHLAND j SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE O[Eav THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 20 E MAIN ST s ACCORDANCE WITH THE POLICY PROVISIONS. ASHLAND OR 97520 AUG 2 ` 20 AUTHORIZED REPRESENTATIVE Attention: MID VALLEY GENERAL AGENCY LLC ~~e'rman R Delss ACORD 25 (2009/09) ©1988-2009 ACORD CORPORATION. All rights reserved. e an ogo are registered marks of ACORD SUPPLEMENT TO CERTIFICATE OF LIABILITY INS #49673 AUGDATE 192011 DESCRIPTION OF OPERATIONS/LOCATIONSNEHICLES/SPECIAL ITEMS THE CITY OF ASHLAND IS INCLUDED AS AN ADDITIONAL INSURED PER ME-009(01/09). COVERED EVENT & DATES: PLAY FOR CHANGE AND FAMILY FITNESS WEEKEND - 08/27/11 & 08/8/11 COVERED LOCATION: 735 JEFFERSON AVE, ASHLAND OR 97520 Certificate # 49673 III ESSEX INSURANCE COMPANY Mum ADDITIONAL INSURED ENDORSEMENT Ent optional if shown in the Common Polic Declarations. If no entry is shown, the effective date of the endorsement is the same as the effective date of the policy. *ATTACHED TO AND FORMING `EFFECTIVE DATE OF *ISSUED TO PART OF POLICY NO. ENDORSEMENT SM-881752 08-17-11 JACKSON COUNTY SART THIS ENDORSEMENT CHANGES THE POLICY. SECTION II - WHO IS AN INSURED of the Commercial General Liability Form is amended to include: Person or Entity: CITY OF ASHLAND Interest of the Above: PLAY FOR CHANGE AND FAMILY FITNESS WEEKEND - 08/27/11 & 08/8/11 735 JEFFERSON AVE, ASHLAND OR 97520 as an additional insured under this policy, but only as respects negligent acts or omissions of the Named Insured and only for occurrences, claims or coverage not otherwise excluded in the policy. It is further agreed that where no coverage shall apply herein for the Named Insured, no coverage nor defense shall be afforded to the above-identified additional insured. Moreover, it is agreed that no coverage shall be afforded to the above-identified additional insured for any "bodily injury," "personal and advertising injury," or "property damage" to any employee of the Named Insured or to any obligation of the additional insured to indemnify another because of damages arising out of such injury. Additional Premium: INCLUDED / AUTHORIZED REPRESENTATIVE DATE M/E-009 (01/09)