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ACOR" DATE(MM/DD/YYYY)
CERTIFICATE OF LIABILITY INSURANCE 05/23/2018
THIS CERTIFICATE IS ISSUED ASA 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:
Katie Enright(731532R) PHONE FAX
560 Hickory St NW Ste 101 (A/C, NO, EXT): 541-926-3068 (A/C, No): 541-704-1160
E-MAIL
Albany OR 97321-1788 ADDRESS: kenright@farmersagent.com
INSURER(S) AFFORDING COVERAGE NAIC #
INSURED INSURER A: Truck Insurance Exchange 21709
INSURER B: Farmers Insurance Exchange 21652
KING OFFICE EQUIPMENT. INC INSURER C: Mid Century Insurance Company 21687
465 PACIFIC BLVD SW
INSURER D:
ALBANY OR 97321 INSURERE:
INSURER F:
COVERAGES CERTIFICATE NUMBER: REVISION NUMBER:
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAME ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY
REQUIREMENT, TERM OR CONDITION OF ANY CONTRACTOR 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 ADDTL SUBR POLICY NUMBER POLICY EFF POLICY EXP LIMITS
LTR INSD WVD (MM/DD/YYYY) (MM/DD/YYYY)
X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 2,000,000
CLAIMS-MADE a OCCUR PRFMISES (Ea DAMAGE RENTED
Occurrence) $ 75,000
MED EXP (Any one person) $ 5.00
B Y N 606219216 06/30/2018 06/30/2019 PERSONAL& ADV INJURY $ 2,000,000
GENT AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 4,000,000
POLICY ❑ PROJECT LOC PRODUCTS - COMP/OPAGG $ 2,000,000
OTHER: $
AUTOMOBILE LIABILITY COMBINED SINGLFLIMIT $ 1,000,000
(Fa accident)
ANYAUTO BODILY INJURY (Per person) $
OWNEDAUTOS SCHEDULED BODILY INJURY (Per accident) $
B ONLY X AUTOS 606219216 06/30/2018 06/30/2019
X HIREDAUTOS X NON-OWNED PROPERTY DAMAGE $
ONLY AUTOS ONLY (Per accident)
UMBRELLA LIAB OCCUR EACH OCCURRENCE $
EXCESS LIAB CLAIMS-MADE AGGREGATE $
DIED RETENTION $ $
WORKERS COMPENSATION PFR OTHER $
AND EMPLOYERS' LIABILITY STATUTE
ANYPROPRIEIOR/PARTNER/ Y/N E.L. EACH ACCIDENT $
EXECUTIVE OFFICER/MEMBER N/A
E.L. DISEASE - EA EMPLOYEE
EXCLUDED? (Mandatory in NH)
If yes, describe under DESCRIPTION OF
E.L. DISEASE - POLICY LIMIT $
OPERATIONS below
DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required)
465 PACIFIC BLVD SW, ALBANY, OR 97321
Additional Insured Listed as City of Ashland
CERTIFICATE HOLDER CANCELLATION
I SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION
Administrative Services Department DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS.
20 E Main St AUTHORIZED REPRESENTATIVE <
ASHI AND no n7ron
ACORD 25 (2016/03) (01988-2015 ACORD CORPORATION. All Rights Reserved
31-1769 11-15 The ACORD name and logo are registered marks ofACORD
POLICY NUMBER 606219216 EUSiNESSOWNERS
RIP 04 48 01 97
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
ADDITIONAL INSURED - DESIGNATED PERSON
OR ORGANIZATION
This endorsement modifies insurance provided under the following:
BUSINESSOWNERS POLICY
SCHEDULE*
Name Of Person Or Organization: CITY OF ASHLAND ADMINISTRATIVE SERVICES DEPART
* Information required to complete this Schedule, if not shown on this endorsement.. will be shown in the Decla-
rations.
The following is added to Paragraph C. Who Is An
Insured in the Businessowners Liability Coverage
Form:
4. Any person or organization shown in the Schedule
is also an insured, but only with respect to liability
arising out of your ongoing operations or premises
owned by or rented to you.
BP 04 48 01 97 Copyright. Insurance Ser,nces Office. Inc . 1997 Page 1 of 1 ❑