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Renewal Declaration
POLICY NUMBER COVERAGE PROVIDED BY FROM - POLICY PERIOD - TO
B 6012100600 VALLEY FORGE INSURANCE COMPANY 04/20/2017 04/20/2018
333 S. WABASH
CHICAGO, IL. 60604
INSURED NAME AND ADDRESS
SEAN NIPPER DBA: REEL HOUSE FILMS
115 WILSON ROAD
ASHLAND, OR 97520
AGENCY NUMBER AGENCY NAME AND ADDRESS
049596 ASHLAND INSURANCE INC
585 A STREET # 1
PO BOX 880
ASHLAND, OR 97520
Phone Number: (541)482-0831
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g BRANCH NUMBER BRANCH NAME AND ADDRESS
050 SEATTLE BRANCH
999 THIRD AVENUE, STE 2500
SEATTLE, WA 98104
Phone Number: (206)587-2600
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This policy becomes effective and expires at 12:01 A.M. standard time at your mailing
address on the dates shown above.
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The Named Insured is an Individual.
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N Your policy is composed of this Declarations, with the attached Common Policy Conditions,
Coverage Forms, and Endorsements, if any. The Policy Forms and Endorsement Schedule shows
all forms applicable to this policy at the time of policy issuance.
The Estimated Policy Premium Is $548.00
Terrorism Risk Insurance Act Premium $11.00
Audit Period is Not Auditable
INSURED Page 1 of 6
POLICY NUMBER INSURED NAME AND ADDRESS
B 6012100600 SEAN NIPPER DBA: REEL HOUSE FILMS
115 WILSON ROAD
ASHLAND, OR 97520
PROPERTY COVERAGE LIMIT OF INSURANCE
The following deductible applies unless a separate deductible is shown on the Schedule of
Locations and Coverage.
Deductible: $500
Business Income and Extra Expense Coverage
Business Income and Extra Expense 12 Months Actual Loss Sustained
Business Income and Extra Expense - Dependent Properties $10,000
Employee Dishonesty $25,000
Forgery and Alteration $25,000
LIABILITY COVERAGE LIMIT OF INSURANCE
Liability and Medical Expense Limit - Each Occurrence $2,000,000
Medical Expense Limit Per Person $10,000
Personal and Advertising Injury $2,000,000
Products/Completed Operations Aggregate $4,000,000
General Aggregate $4,000,000
Damage To Premises Rented To You $300,000
Employment Practices/Fiduciary Liability Retroactive Date: 04/20/2015 $10,000
EPLI Deductible: $0
Hired Auto Liability $1,000,000
Nonowned Auto Liability $1,000,000
Photographers & Videographers Errors & Omissions Liability
Each Occurrence Limit $500,000
Aggregate Limit $1,000,000
INSURED Page 2 of 6
POLICY NUMBER INSURED NAME AND ADDRESS
B 6012100600 SEAN NIPPER DBA: REEL HOUSE FILMS
115 WILSON ROAD
ASHLAND, OR 97520
SCHEDULE OF LOCATIONS AND COVERAGE
LOCATION 1 BUILDING 1
115 WILSON ROAD
ASHLAND, OR 97520
Construction: Frame
Class Description: Videographer
Broadened Wind
Inflation Guard 3%
PROPERTY COVERAGE LIMIT OF INSURANCE
Accounts Receivable $25,000
Building Not Covered
Business Personal Property $5,202
Electronic Data Processing $50,000
Equipment Breakdown $5,202
Fine Arts $25,000
Ordinance or Law - Demolition Cost, Increased Cost of Construction $25,000
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Seasonal Increase: 25%
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Sewer or Drain Back Up $25,000
L0 Valuable Papers & Records $25,000
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INSURED Page 3 of 6
EOLICY NUMBER INSURED NAME AND ADDRESS
B 6012100600 SEAN NIPPER DBA: REEL HOUSE FILMS
115 WILSON ROAD
ASHLAND, OR 97520
ADDITIONAL INTEREST SCHEDULE
LOCATION 1 BUILDING 1
Type: State, Political-Permits
Additional Interest Name and Address:
CITY OF ASHLAND
20 EAST MAIN ST
ASHLAND OR 97520
LOSS PAYEE SCHEDULE
All loss payees as their interests may appear in the Covered Property.
The following provisions apply in accordance with the insurable interest of the loss
payee: Loss Payee
Description of Property: Any Covered Property in which a loss payee, creditor or lender
holds an interest, including any person or organization you have entered a contract with
for the sale of Covered Property.
INSURED Page 4 of 6