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HomeMy WebLinkAboutInsurance Certificate: Pony Espresso DATE (MM/DD/YYYY) AC" CERTIFICATE OF LIABILITY INSURANCE 02/20/2017 THIS CERTIFICAT IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DO S NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS C RTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIV OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If th certificate holder is an ADDITIONAL INSURED, the policy(ies) must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION S WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate doe not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT NAME: Hart Insurance Agency - Medford PHONE Kristi Dolmage FAX 1123 Royal Ave AC No Ext: (541) 779-4232 A/C No: E-MAIL Medford OR 975041, ADDRESS: INSURERS AFFORDING COVERAGE NAIC # INSURER A: American Hallmark Insurance Co 43494 INSURED (541) 821-4488 INSURER B CK Coffee Co. LL dba: Pony Espres o INSURERC: P O BOX 1536 INSURER D : Jacksonville OR 7 530 INSURER E : INSURER F : COVERAGES CERTIFICATE NUMBER: Cert ID 2820 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 B ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND C NDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF I SURANCE ADDL SUBR POLICY EFF POLICY EXP LIMITS LTR POLICY NUMBER MM/DD/YYYY MM/DD/YYYY A X COMMERCIALG NERALLIABILITY EACH OCCURRENCE $ 11000,000 DAMAGE TO RENTED CLAIMS-MA E X OCCUR 44PB487310 03/24/2017 03/24/2018 PREMISES Ea occurrence $ 100,000 MED EXP (Any one person) $ 5 , 000 PERSONAL & ADV INJURY $ GEN'L AGGREGATE LI IT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 X POLICY FJE T 1-1 LOC PRODUCTS - COMP/OP AGG $ OTHER: $ AUTOMOBILE LIABILIT COMBINED SINGLE LIMIT $ Ea accident ANY AUTO BODILY INJURY (Per person) $ OWNED SCHEDULED BODILY INJURY (Per accident) $ AUTOS ONLY AUTOS HIRED NON-OWNED PROPERTY DAMAGE AUTOS ONLY X AUTOS ONLY Per accident $ $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETE TION $ $ WORKERS COMPENSAT ON PER DTH- AND EMPLOYERS' LIABI ITY Y I N STATUTE ER ANYPROPRIETOR/PART ER/EXECUTIVE E.L. EACH ACCIDENT $ OFFICERIMEMBEREXCLI DED? ❑ 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 OPERATION' I LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) RE: 175 Lithia Wa , Ashland, OR 97520 CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN City of Ashland ACCORDANCE WITH THE POLICY PROVISIONS. 20 E. Main Street AUTHORIZED REPRESENTATIVE Ashland OR 97520 1 i ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016103) The ACORD name and logo are registered marks of ACORD Page 1 of 1