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HomeMy WebLinkAboutInsurance Certificate: Brenntage Pacific, Inc DATE /YYYY) CERTIFICATE OF LIABILITY INSURANCE ,2(2612n017 o1 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 Marsh USA Inc. NAME: PHONE FAX 1717 Arch Street LAIC. Nv W: (AIC, No); Philadelphia, PA 19103-2797 E-MAIL ADDRESS: INSURER(S) AFFORDING COVERAGE NAIC # 424780-"ALL-GAW-18-19 INSURER A : Insurance Company Of The State Of PA 19429 INSURED INSURER 22667 BRENN TAG PACIFIC, INC INSURER 13: ACE American Insurance Company___ 10747 PATTERSON PLACE INSURER C : Indem_ nity Insurance Company of North America 43575 SANTA FE SPRINGS, CA 90670 42757 INSURER o : AAqri General_Insurance Co_m_Qa~_ INSURER E : ACE Fire Underwriters Co 20702 INSURER F : COVERAGES CERTIFICATE NUMBER: CLE-006117481-33 REVISION NUMBER: 12 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 - jADDL SUBR POLICY EFF POLICY EXP LIMITS LTR TYPE OF INSURANCE POLICY NUMBER MM/DD/YYYY MM/DDIYYYY A X COMMERCIAL GENERAL LIABILITY GL6634468 01/01/2018 01101019 EACH OCCURRENCE $ 2,000,000 _DAMAGE Td RENTED _ CLAIMS-MADE FX 1 OCCUR _PREMISES Ea occurrence $ 1,000,000 MED EXP (Any one person) $ 10.000 PERSONAL & ADV INJURY $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER. GENERAL AGGREGATE $ 2,000,000 PRO- - X POLICY JECT LOC PRODUCTS - COMP/OP_AGG $ 2,000,000 OTHER - - B AUTOMOBILE LIABILITY ISAH25098274 01/01/2018 01/0112019 COMBINED SINGLE LIMIT - I $ 1,000,000 Ea acodenl X ANY AUTO r OWNED SCHEDULED BODILY INJURY (Per accident) $ AUTOS ONLY AUTOS F - i HIRED NON-OWNED PROPERTYDAMAGE $ AUTOS ONLY AUTOS ONLY (Per accident] $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ - EXCESS LIAR f CLAIMSMADE AGGREGATE )ED `RETEN1 ION $ $ C WORKERS COMPENSATION WLRC64623813(AOS) 01/7 01/01/2019 X PER OTH- AND EMPLOYERS' LIABILITY - STATUTE _ ER B YIN WLRC64623825 (CA, MA, AZ) 01101,2C18 01101/019 2.000.000 ANYPROPRIETOWPARINER/EXECUTIVE E_._L_. EACH_A_C_CIDENT $ D OFFI( ER/MEMBER EXCLUDED? NlA WLRC64623837 01/0112018 01/01J2019 (Mandatory in NH) (TN) E.L. DISEASE - EA_ EMPLOYEE 2,000.000 E It yes describe under SCFC64623849 (WI) 01/01/2018 10110112019 2,000,000 DESCRIPTION OF OPERATIONS below EL DISEASE -POLICY LIMIT $ I I I DESCRIPTION OF OPERATIONS / LOCATIONS 1 VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) RE SUPPLYING CHEMICALS 10 BOTH THE WATER TREATMENT PLANT LOCATED AT 90 N MOUNTAIN AVENUE, ASHLAND, OR 91520 AND TI ,E 'WASTE WATER 1RF:P TMEN T PLANT LOCATED A I 1195 OAK STREET, ASHLAND OR 97520. THE CITY OF ASHLAND, OREGON, AND ITS ELECTED OFFICIALS, OFFICERS AND EMPLOYEES ARE INCLUDED AS ADDITIONAL INSURED, L-XCEPT FOR iNORKF.,R~&Oti1PErdSAT10N WHERE REQUIRED BY WRITTEN CONTRACT CERTIFICATE HOLDER CANCELLATION CITY OF ASHLAND. OR SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE ATTN. KARI OLSON THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 90 NORTH MOUNTAIN AVENUE ACCORDANCE WITH THE POLICY PROVISIONS. ASHLAND, OR 97520 AUTHORIZED REPRESENTATIVE of Marsh USA Inc. Manashi Mukherlee a~tpo~- ~d,uct_haA4 -A ©1988-2016 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD