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HomeMy WebLinkAboutInsurance Certificate: Noble Coffee Roasting ® DATE (MM/DD/YYYY) AC "R& CERTIFICATE OF LIABILITY INSURANCE 03/06/2017 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 D Wick Hart Insurance Agency - Medford PHONE FAX PO Box 1240 A/C No Ext: (541) 779-4232 A/C No: E-MAIL Grants Pass OR 97528 ADDRESS: INSURERS AFFORDING COVERAGE NAIC # INSURERA:American Hallmark Insurance Co 43494 INSURED (541) 488-3288 INSURERB: SAIF Corporation 36196 Noble Coffee Roasting LLC INSURER C : 281 Fourth Street INSURER D: Ashland OR 97520 INSURER E: INSURER F : COVERAGES CERTIFICATE NUMBER: Cert ID 2969 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 ADDL SUBR POLICY EFF POLICY EXP LIMITS LTR TYPE OF INSURANCE POLICY NUMBER MM/DD/YYYY MM/DD/YYYY A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 11000,000 DAMAGE TO CLAIMS-MADE ~ OCCUR Y 44PB463752 04/13/2017 04 /13 /2018 PREMISES (Ea occur ence $ 100,000 MED EXP (Any one person) $ 5 , 0 0 0 PERSONAL SADV INJURY $ 11000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 PRO- ❑ LOC PRODUCTS - COMP/OP AGG $ 2,000,000 POLICY X JECT F7 OTHER: AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ 11000,000 Ea accident A ANY AUTO 44PB463752 04/13/2017 04/13/2018 BODILY INJURY (Per person) $ OWNED SCHEDULED BODILY INJURY (Per accident) $ AUTOS ONLY X AUTOS HIRED NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY AUTOS ONLY Per accident UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION $ $ ~PER STATUTE OERH WORKERS COMPENSATION 776066 01/01/2017 01/01/2018 X B AND EMPLOYERS' LIABILITY ANYPROPRIETOR/PARTNER/EXECUTIVE Y❑ NIA E.L. EACH ACCIDENT $ 11000,000 OFFICER/MEMBER EXCLUDED? (Mandatory in NH) E.L. DISEASE -EA FMPI_.OYEE $ 1,000,000 If yes, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT $ 11000,000 DESCRIPTION OF OPERATIONS I LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) Certificate holder is additional insured per attached CBP045 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 St AUTHORIZED REPRESENTATIVE Ashland OR 97520 ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016103) The ACORD name and logo are registered marks of ACORD n,-- , I POLICY NUMBER: COMMERCIAL ADVANTAGE POLICY CBP 047 03 05 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - MANAGERS OR LESSORS OF PREMISES This endorsement modifies insurance provided under the following: COMMERCIAL ADVANTAGE POLICY SCHEDULE Name Of Person Or Organization: Location Of Premises (Part Leased To You): Information required to complete this Schedule, if not shown on this endorsement, will be shown in the Declara- tions. The following is added to Paragraph C. Who Is An Insured in Section II - Liability: 4. The person or organization shown in the Schedule is also an insured, but only with respect to liability arising out of the ownership, maintenance or use of that part of the premises leased to you and shown in the Schedule. This insurance does not apply to any "occurrence" that takes place after you cease to be a tenant in the premises shown in the Schedule or structural alterations, new construction and demolition operations performed by or for the person or organization designated in the Schedule. CBP 047 03 05 Includes copyrighted material of Insurance Services Office., Inc., Page 1 of 1 ❑ with its permission