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HomeMy WebLinkAboutInsurance Certificate: Pacific Mobile Structures inc. COMMERCIAL LINES - (206) 731-1200 USI INSURANCE SERVICES NATIONAL, INC. - CA LIC#: OD084 999 THIRD AVE, SUITE 4100 1 W2 SEATTLE, WA 98104 CITY OF ASHLAND 20 EAST MAIN STREET ASHLAND OR 97520 i I I I ***#**#*****#*#*#*##**###########*#*#***********#X**#*#*####*#**#**fiX**fi*XX*fiX###**#***#***********###**###*######## Would you like to receive this certificate via email or fax? We offer expedited delivery to better serve our mutual clients. To update the delivery method for revisions to this certificate and for next year's copy, please enter this information in your browser: https://www.cybersure.com/cybersure/forms/iyoc/cdmu.aspx When prompted, enter this information for security purposes: Client ID: 360077 Cert ID: 12631285 Passcode: BDE4EEFA Follow the instructions and let us know your delivery preference. You'll receive future copies of this certificate via the method you provide. Thank you for helping us provide certificates to you more quickly. ICYB01A26/00119201/020/0/0/0' 360077 DATE (MMIDDlYYYY) Aco CERTIFICATE OF LIABILITY INSURANCE 1/24/2018 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: Brenda S_ch_o_r_nak _ Commercial Lines - (206) 731-1200 PHONE I FAX A/C No Ems: 206_731-1200 {wc, No)_ 610-537-2350 USI Insurance Services National, Inc. - CA Lic#: 0008408 ADDR SS: brenda.schomak@usi.com 999 Third Ave, Suite 4100 INSURER(S) AFFORDING COVERAGE NAIC k Seattle, WA 98104 _ INSURERA: West American Insurance Company 44393 INSURED INSURER B: American Fire and Casualty Company 24066 Pacific Mobile Structures Inc INSURERC: PO Box 1404 INSURER D : INSURER E : Chehails WA 98532 INSURER F : COVERAGES CERTIFICATE NUMBER: 12631285 REVISION NUMBER: See below 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 1 ADDL SUBR- I POLICY EFF POLICY EXP LIMITS LTR TYPE OF INSURANCE IN SD WVD POLICY NUMBER MMIDDlYYYY MMIDDlYYYY A X COMMERCIAL GENERAL LIABILITY B KW(1 9) 57624779 01/31/2018 01131/2019 EACH OCCURRENCE S 1,000,000 DAMAGE TO RENTE CLAIMS-MADE I OCCUR PREMISES Ea occur ence S 1,000,000 MED EXP (Any one person) S 15,000 PERSONAL 8 ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 RO- POLICY 7 JECT F7 LOC PRODUCTS - COMP/OP AGG $ 2,000,000 OTHER' S B AUTOMOBILE LIABILITY BAA(19)55555944 01/31/2018 01/31/2019 EOaBW.DISINGLELIMIT S 1,000,000 x ANY AUTO BODILY INJURY (Per person) " OWNED SCHEDULED BODILY INJURY (Per accident) S AUTOS ONLY AUTOS HIRED NON-OWNED 1 PROPERTY DAMAGE S AUTOS ONLY AUTOS ONLY Per accident S UMBRELLALIAB OCCUR EACH OCCURRENCE S EXCESS LIAB CLAIMS-MADE AGGREGATE S I DED RETENTIONS S WORKERS COMPENSATION 01/31/2016 01/31/2019 STATUTE ERH A AND EMPLOYERS' LIABILITY YIN XWW(19) 56976329 ANYPROPRIETORIPARTNER/EXECUTIVE OR, TX, CA, ID E.L. EACH ACCIDENT S 1,000,000 OFFICER/MEMBER EXCLUDED? 71 N/A (Mandatory in NH) EL DISEASE - EA EMPLOYEE! S 1,000,000 If as, describe under ! DESCRIPTION OF OPERATIONS below I E.L. DISEASE - POLICY LIMIT S 1,000,000 A WA Stop Gap i BKW(19) 57624779 01131!2018 01/3112019 $1,000,000 Each Acc. $1,000,000 Each Emp. $2,000,000 Agg. DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) The City of Ashland, Oregon, and its elected officials, officers and employees are additional insured as respects the operations of the named insured. CANCELLATION CERTIFICATE HOLDER SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE City of Ashland THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 20 East Main Street ACCORDANCE WITH THE POLICY PROVISIONS. Ashland OR 97520 AUTHORIZED REPRESENTATIVE The ACORD name and logo are registered marks of ACORD ©1988-2015 ACO/RD" rCORPORATION. All rights reserved. ACORD 25 (2016103) 1111 11~ I 111[ 11 III 1[~ III 11~ 1111 1~~ 111 I 111 •CYBO1A26/001192/02r021000i0•