HomeMy WebLinkAboutInsurance Certificate: Rogue Valley Dust Control
CERTIFICATE OF LIABILITY INSURANCE °9i2oi2019 '
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 endarsement. A statement on
this certificate does not confer rights to the certificate holder in lieu of such endorsement(s).
PRODUCER PROTECTORS INSURANCE LLC CONTACT NAME:
PO BOX 4669 PHONE FAX
MEDFORD, OR 97501 ac No. EXt: A/C, No.:
E-MAILADDRESS:
PHONE NO. (541)773-5358 INSURER(S) AFFORDING COVERAGE NAIC#
INSURED MICHAEL FALCO INSURERA: RED SHIELD INSURANCE COMPANY 41580
DBA: ROGUE VALLEY DUST CONTROL INSURER B:
2744 HOWARD AVE INSURER C:
MEDFORD, OR 97501
INSURER D:
INSURER E:
INSURER F:
COVERAGES CERTIFICATE NUMBER: - - REVISION NUMBER: -
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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 NUMBER POLICY EFF POLICY EXP LIMITS
LTR INSR MD (MM/DDIYYYY) (MWDDNYYY)
GENERAL LIABILITY EACH OCCURRENCE 1,000,000
A X COMMERCIAL GENERAL LIABILITY ZA AGE TORENTED PREMISES 100,000
CLAIMS-MADE OCCUR X CLP 024987 1011412019 10/1412020 MED EXP (Anyone person) 5,000
PERSONAL SADV INJURY 1,000,000
GENERAL AGGREGATE 2,000,000
GEN'L AGGREGATE LIMIT APPLIES PER PRODUCTS - COMP/OP AGG EXCLUDED
X POLICY PROJECT LOG
COMBINED SINGLE LIMIT
AUTOMOBILE LIABILITY E
ANY AUTO BODILY INJURY (Per person)
OWNED SCHEDULED
AUTOS ONLY AUTOS BODILY INJURY (Per accident)
HIRED NON-OWNED
AUTOS ONLY AUTOSONLY PROPERTY DAMAGE (Per accident)
UMBRELLAUAB OCCUR EACH OCCURRENCE
EXCESS LIAR CLAIMS-MADE AGGREGATE
OED RETENTION
WORKERS COMPENSATION WC STAMORY OTHER Idn's AND EMPLOYERS' LIABILITY VM
ANY PROPRIETOR PARTNERIEXECUTIVE ❑ WA _ E. L. EACH ACCIDENT
OFFICER MEMBER EXCLUDED?
(Mandatary in NN) E. L. DISEASE - EA EMPLOYEE
If yes, tlescribe under
DESCRIPTION OF OPERATIONS below E. L. DISEASE - POLICY LIMIT
DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarla Schedule. may be attached it mom space is required)
ROADWAY DUST CONTROL SPRAYING
The Certificate Holder is included as an additional insured pursuant to ISO form GL 1115(11/15) a copy ofwhich is
attached hereto for informational purposes.
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE
CANCELLED BEFORE THE EXPIRATION DATE THEREOF,
CITY OF ASHLAND NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE
PUBLIC WORKS DEPARTMENT POLICY PROVISIONS.
20 E MAIN ST AUTHORIZED REPRESENTATIVE
ASHLAND, OR 97520
1988.2D15 ACORD CORPORATION. All rights reserved.
ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD
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POLICY NUMBER: CLP 024987 COMMERCIAL GENERAL LIABILITY
GL 11 15 11 15
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
ADDITIONAL INSURED - OWNERS, LESSEES OR CONTRACTORS
SCHEDULED PERSON OR ORGANIZATION
This endorsement modifies insurance provided under the following:
COMMERCIAL GENERAL LIABILITY COVERAGE PART
SCHEDULE
Name of Person or Organization: CITY OF ASHLAND
PUBLIC WORKS DEPARTMENT
20 E MAIN ST
ASHLAND, OR 97520
A. Section II - Who Is An Insured is amended to 4. The person or organization are not additional
include as an additional insured the additional insureds for liability arising out of their own
insured(s) shown in the Schedule, when you and negligence, or the "products completed
such person or organization have agreed in writing operations hazard".
in a contract or agreement that such person or
organization you are contracting with be added as C. With respect to the insurance afforded to the
an additional insured on your policy. Such person or additional insureds the following limitations and
organization is an additional insured only with exclusions apply:
respect to "bodily injury" or "property damage" This insurance does not apply to, and the additional
occurring subsequent to execution of the written insureds are not insureds for:
contract or agreement, while you are performing
your ongoing operations at the person's or 1. "Bodily injury", "property damage" or "personal
organization's premises, and caused only by your and advertising injury" arising out of the
negligence in the performance of those operations. rendering of, or the failure to render, any
The person's or organization's status as an professional architectural, engineering or
additional insured ends when your personnel are no surveying services, including:
longer present at the premises of the person or
organization. a. The preparing, approving, or failing to
prepare or approve, maps, shop drawings,
B. The insurance provided to the additional insureds is opinions, reports, surveys, field orders,
limited as follows: change orders or drawings and
specifications; and
1. Any insurance afforded to such additional
insureds by this endorsement only applies to the b. Supervisory, inspection, architectural or
extent permitted by law; and engineering activities.
2. If coverage provided to the additional insured is This limitation and exclusion applies even if the
required by a contract or written agreement, the claims against an insured allege negligence or other
insurance afforded to such additional insured wrongdoing in the supervision, hiring, employment,
will not be broader than that which you are training or monitoring of others by that insured, if
written agreement to the "occurrence" which caused the "bodily injury" or
required by the contract than
provide for such additional insured; and "property damage", or the offense which caused the
"personal and advertising injury", involved the
3. The person or organization is an additional rendering of or the failure to render any professional
insured only for vicarious liability resulting from architectural, engineering or surveying services.
your negligent acts; and
GL 11 15 11 15 Includes copyrighted material of Insurance Services Office, Inc., with its permission. Page 1 of 2
2. "Bodily injury", "property damage" or "personal
and advertising injury" occurring after:
a. All work, including materials, parts or
equipment furnished in connection with such
work, or the project (other than service,
maintenance or repairs) to be performed by
or on behalf of the additional insured(s) at the
location of the covered operations has been
completed; or
b. That portion of "your work" out of which the
injury or damage arises has been put to its
intended use by any person or organization
other than another contractor or
subcontractor engaged in performing
operations for a principal as part of the same
project.
D. Coverage afforded to the additional insured is no
greater than that provided to you and is subject to
all policy terms, conditions, and exclusions,
including those applicable to other insurance, to the
same extent they are applicable to you.
E. The following duties are added to the Duties in
Event of Occurrence, Offense, Claim or Suit
Condition of this policy: Additional insureds under
this endorsement shall tender any claim or "suit" to
all available insurance and shall give written notice
to us of any "occurrence" which may result in a
claim or "suit" under this insurance.
F. With respect to the insurance afforded to these
additional insureds, the following is added to
Section III - Limits Of Insurance:
The most we will pay on behalf of the additional
insured is the amount of insurance:
1. Required by the written contract or agreement
you have entered into with the additional
insured; or
2. Available under the applicable Limits of
Insurance shown in the Declarations;
whichever is less.
This endorsement shall not increase the applicable
Limits of Insurance shown in the Declarations.
GL 11 15 11 15 Includes copyrighted material of Insurance Services Office, Inc., with its permission. Page 2 of 2