HomeMy WebLinkAboutInsurance Certificate: Louies Bar & Grill
AC40 CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DD/(YYY}
164.~ 2/28/2017
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 have ADDITIONAL INSURED provisions or 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
NAME: Kristin Wick
Hart Insurance Agency - Medford PHONE FAX
PO Box 1240 A/C No Ext : (541) 779-4232 A/C No :
E-MAIL
ADDRESS:
Grants Pass OR 97528
INSURERS AFFORDING COVERAGE NAIC #
INSURERA:American Hallmark Insurance Co 43494
INSURED (541) 482-9701 INSURER B :
Louie's Bar & Grill LLC dba: Louie's Bar &
Grill INSURER C :
41 N Main St. INSURERD:
Ashland OR 97520 INSURER E:
INSURER F :
COVERAGES CERTIFICATE NUMBER: Cert ID 2926 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 ADD- SUER POLICY NUMBER MM/DDY EFF POLICY EXP
/YYYY MM/DD LIMITS
A JX COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 11000,000
DAMAGE TO RENTED
CLAIMS-MADE 1 7X OCCUR Y 44PB500406 9/1/2016 9/1/2017 PREMISES Eaoccurrence) $ 100,000
MED EXP (Anyone person) $ 5,000
PERSONAL & ADV INJURY $ 11000,000
GENI AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000
POLICY E PRO ❑ LOC PRODUCTS -COMP/OP AGG $ 2,000,000
JECT
OTHER: Liquor $ 11000,000
AUTOMOBILE LIABILITY 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 AUTOS ONLY Per accident
$
UMBRELLA LIAB OCCUR EACH OCCURRENCE $
EXCESS LIAR CLAIMS-MADE AGGREGATE $
DED RETENTION $ $
WORKERS COMPENSATION PER OTH-
AND EMPLOYERS' LIABILITY Y/N STATUTE ER
ANYPROPRIETOR/PARTNER/EXECU I IVE E.L. EACH ACCIDENT $
OFFICER/MEMBEREXCLUDED? 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 t VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached If more space Is required)
City of Ashland is an Additional Insured per the attached CBP047 03/05 in regards to the outside
seating area.
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
City of Ashland
20 E Main Street AUTHORIZED REPRESENTATIVE
Ashland OR 97520
C 1988-2015 ACORD CORPORATION. All rights reserved.
ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD
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