HomeMy WebLinkAboutInsurance Certificate: Pacific Mobile Structures Inc. (2)
360077
DATE (MMIDD/YYYY)
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 Schomak
Commercial Lines - (206) 731-1200 PHONE 206-731-1200 FAX 610-537-2350
A/C No Ext : AlC Na
USI Insurance Services National, Inc. - CA Lic#: OD08408 E-MAIL
ADDRESS: brenda.schomak@usi.cem
999 Third Ave, Suite 4100 INSURER(S) AFFORDING COVERAGE NAIC #
Seattle, WA 98104 INSURERA: West American Insurance Company 44393
INSURED INSURER B: American Fire and Casualty Company 24066
Pacific Mobile Structures Inc
INSURER C:
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 TYPE OF INSURANCE ADDL SUBR POLICY EFF POLICY EXP LIMITS
LTR INSD WVD POLICYNUMBER MM/DD/YYYY MMIDD/YYYY
A X COMMERCIAL GENERAL LIABILITY BKW(19)57624779 01/31/2018 01/31/2019 EACH OCCURRENCE S 1,000,000
DAMAGE TO-RS_NTE1T_
CLAIMS-MADE F~] OCCUR PREMISES Ea occurrence) S 1,000,000
MED EXP (Any one person) $ 15,000
PERSONAL & ADV INJURY S 1,000,000
GEN'LAGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE S 2,000,000
R POLICY PRO- LOC PRODUCTS - COMP/OP AGG S 2,000,000
OTHER: S
B AUTOMOBILE LIABILITY BAA(1 9) 55555944 01/31/2018 01/31/2019 MBINEDSINGLELIMIT $ 1,000,000
X ANY AUTO BODILY INJURY (Per person) $
OWNED SCHEDULED BODILY INJURY (Per accident) S
AUTOS ONLY AUTOS
HIRED NON-OWNED PROPERTY DAMAGE S
AUTOS ONLY AUTOS ONLY Per accident
$
UMBRELLALIAB OCCUR EACHOCCURRENCE S
EXCESS LIAB CLAIMS-MADE AGGREGATE S
Dec) F-FRETENTION $ S
WORKERS COMPENSATION 01/31/2018 01!31/2019 STATUTE ERH
A AND EMPLOYERS' LIABILITY YIN XW W(19) 56976329
ANYPROPRIETOR/PARTNER]EXECUTIVE OR, TX, CA, ID E.L. EACH ACCIDENT S 1,000,000
OFFICERIM EMBER EXCLUDED? El NIA
(Mandatory in NH) E.L. DISEASE- EA EMPLOYEE S 1,000,000
If yes, describe under 1,000,000
DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT S
A WA Stop Gap BKW(19) 57624779 01/3112018 01131/2019 $1,000,000 Each Acc.
$1,000,000 Each Emp.
$2,000,000 Agg.
DESCRIPTION OF OPERATIONS / LOCATIONS /VEHICLES (ACORD 101, Additional Remarks Schedule, maybe 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.
I
CERTIFICATE HOLDER ' CANCELLATION
City of Ashland SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
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 ACORD CORPORATION. All rights reserved.
ACORD 25 (2016103)