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HomeMy WebLinkAboutInsurance Certificate: Pacific Benefit Consultants l a DATE (MM/DD/YYYY) ACoRD CERTIFICATE OF LIABILITY INSURANCE 3/28/2017 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 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: Tammy Ann Syrek Pacific Benefit Consultants PHONE (541) 484-6624 FAX (541) 68 6-272 6 A/C No Ext : A/C No): SS:tsyrek@pbcins.com 450 Country Club Road #330 E-MAIL INSURER(S) AFFORDING COVERAGE NAIC # Eugene OR 97401 INSURER A :Sentinel Insurance Company 11000 INSURED INSURER B :MUtUal of Enumclaw Insurance 14761 Mortier Engineering, Pe, Pc INSURERC:SAIF Corp 144 E 14th Ave INSURER D :MaXum Specialty Insurance INSURER E : Eugene OR 97401 INSURER F : COVERAGES CERTIFICATE NUMBER:CL173620446 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/DDIYYYY X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 2,000,000 DAMAGE TO A CLAIMS-MADE ❑ OCCUR PREMISES (Ea occur ence $ 1,000,000 52SBANN7141 5/7/2017 5/7/2018 MED EXP (Any one person) $ 10 , 000 PERSONAL & ADV INJURY $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER GENERAL AGGREGATE $ 4,000,000 ❑ PRO- ❑ 4 000 000 X POLICY JECT LOC PRODUCTS COMP/OP AGG $ Employment Practices Liab Ins $ 10 , 000 OTHER: 1 AUTOMOBILE LIABILITY Ea aBINEDiSINGLE LIMIT $ 1,000,000 ANY AUTO BODILY INJURY (Per person) $ B ALL OWNED SCHEDULED AUTOS X AUTOS BAP0004480 5/7/2017 5/7/2018 BODILY INJURY (Per accident) $ NON-OWNED PROPERTY DAMAGE $ X HIRED AUTOS X AUTOS Per accident Uninsured motorist combined $ 1,000,000 X UMBRELLA LIAB OCCUR EACH OCCURRENCE $ 4,000,000 A EXCESS LIAB CLAIMS-MADE AGGREGATE $ 4,000,000 X 52SBANN7141 5/7/2017 5/7/2018 DED RETENTION $ 10 000 $ WORKERS COMPENSATION X PER OTH- AND EMPLOYERS' LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE YLJ STATUTE ER N/A E.L EACH ACCIDENT $ 500 , 000 OFFICER/MEMBER EXCLUDED? I C 951252 (Mandatorv in NH) 4/1/2017 411/2018 E L DISEASE - EA EMPLOYE 1 500 , 0.,)C, If yes, describe under DESCRIPTION OF OPERATIONS below E L. DISEASE - POLICY LIMIT $ 500,000 D Professional Liability PFY602559i03 12/3/2016 12/3/2017 $1.nGo,000 Re terti4 c)n $2.000,000 $10,000 I DESCRIPTION OF OPERATIONS / LOCATIONS ! VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE City of Ashland THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Community Development Department ACCORDANCE WITH THE POLICY PROVISIONS. 51 Winburn Way Ashland, OR 97520 AUTHORIZED REPRESENTATIVE Tarmv Svrek/TAS - f © 1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25 (2014/01) The AC~)RD name and logt~ are registered marks of ACORD INS025 (201401) Additional Named Insureds Other Named Insureds The Building Department LLC Additional. Insured OFAPPINF (02/2007) COPYRIGHT 2007, AMS SERVICES INC