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HomeMy WebLinkAboutInsurance Certificate: OR Dept of Forestry Procurement Office DATE (MM/DD/YYYY) ~ CERTIFICATE OF LIABILITY INSURANCE 8/27/2014 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. 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 CONTACT Sand Orr NAME: y Brown & Brown Northwest PHONE.Etle (541) 772_1111 FAAX No : (541)772-3785 3256 Hillcrest Park Drive E-MAIL . sorr@bbnw. com INSURERS AFFORDING COVERAGE NAIC # Medford OR 97504 INSURERA Midwest Employers Casualty Co 3612 INSURED INSURER B : City Of Ashland INSURER C : 20 E Main St INSURER D : INSURER E : Ashland OR 97520 INSURER F : COVERAGES CERTIFICATE NUMBER:14-15 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, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCE ADDILSUBRI %NVD POLICY NUMBER MM/DCD/YYYY MM1DDY EXP LTR /YYYY LIMITS GENERAL LIABILITY EACH OCCURRENCE $ DAMAGE O RENTED COMMERCIAL GENERAL LIABILITY PREMISES Ea occurrence $ CLAIMS-MADE F-IOCCUR MED EXP (Any one person) $ PERSONAL & ADV INJURY $ GENERAL AGGREGATE $ GEN'L AGGREGATE LIMIT APPLIES PER PRODUCTS - COMP/OP AGG $ RO LOC $ -1 POLICY P F JECT AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea accident $ ANY AUTO BODILY INJURY (Per person) $ ALL OWNED SCHEDULED BODILY INJURY (Per accident) $ AUTOS AUTOS HIRED AUTOS NON- PROPERTY DAMAGE $ AUTOS OWNED Per accident UMBRELLA LIAB H OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION $ $ A WORKERS COMPENSATION X WC STATU- OTH- AND EMPLOYERS' LIABILITY Y /N TORY LIMIT ER ANY PROPRIETOR/PARTNER/EXECUTIVE E.L. EACH ACCIDENT $ 1,000,000 OFFICER/MEMBER EXCLUDED? N/A EW0008757 7/1/2014 7/1/2016 (Mandatory in NH) E.L. DISEASE - EA EMPLOYE $ 1,000,000 If yes, describe under Retention All Other $500, 000 DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT $ 1,000,000 Retention - Codes 7539, $750,000 7720 & 7710 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required) American Recovery & Reinvestment Act Funded Program Grant between ODF and Ashland Parks Department. CERTIFICATE HOLDER CANCELLATION poverhulser@ odf . state . or . u SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Oregon Department of Forestry ACCORDANCE WITH THE POLICY PROVISIONS. Procurement Office Attn: Pam Overhulser, Grant Operations C AUTHORIZED REPRESENTATIVE 2600 State Street Salem, OR 97301 Sandy Orr/SANDOR ACORD 25 (2010105) ©1988-2010 ACORD CORPORATION. All rights reserved. INS025 (201005).01 The ACORD name and logo are registered marks of ACORD