HomeMy WebLinkAboutInsurance Certificate: Polydyne Inc.ACOROP CERTIFICATE OF LIABILITY INSURANCE
DATE(MMIDD/YYYY)
1
lll.�
12/24/2019
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 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 Phone No.: (212) 488-0200
CONTACT
Fax No.: (212) 488-0220
NAME:
PHONE FAX
EPIC Insurance Brokers & Consultants
ac NO EM'
E-MAIL
ADDRESS:
350 Hudson Street — 4th Floor
INSURER(Si AFFORDING COVERAGE
NAIC #
New York, NY 10014
INSURER A: AIG SPECIALTY INSURANCE COMPANY
26883
INSURED
INSURER B: COMMERCE & INDUSTRY INSURANCE COMPANY
19410
INSURER C: HARTFORD FIRE INSURANCE COMPANY
19682
Polydyne Inc.
One Chemical Plant Road
INSURER D:
PO Box 250
Riceboro GA 31323
INSURER E:
INSURER F:
COVERAGES CERTIFICATE NUMBER: REVISION NUMBER:
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
L7R
ADDL
INSD
SUBR
WVD
POLICY NUMBER
POLICY EFF POLICY EXP
YL.LIMITS
A X COMMERCIAL GENERAL LIABILITY
CLAIMS -MADE X I OCCUR
Y
EG14362834
12/31/2019
12/31/2020
EACH OCCURRENCE
$1,000,000
DAMAGE TO RENTED
PREMISES Ea occurrence
$500,000
MED EXP (Any one person)
$25,000
PERSONAL & ADV INJURY
$1,000,000
GEN'L AGGREGATE LIMIT APPLIES PER:
POLICY PRO-
L�IJECT 17 LOC
GENERAL AGGREGATE
$2,000,000
PRODUCTS - COMP/OP AGG
$2,000,000
OTHER:
$
B AUTOMOBILE
X
LIABILITY
ANY AUTO
Y
CA4691818
12/31/2019
12/31/2020Ea
aMBINED SINGLE LIMIT
ccident
$1,000,000
BODILY INJURY (Per person)
$
ALL OWNED SCHEDULED
AUTOS AUTOS
BODILY INJURY (Per accident)
$
X
HIRED AUTOS X NON -OWNED
AUTOS
PROPERTY DAMAGE
Per accident
$
$
A
UMBRELLA LIAR
X
OCCUR
EGU18403155
12/31/2019
12/31/2020
EACH OCCURRENCE
$3,000,000
X
EXCESS LIAB
CLAIMS -MADE
AGGREGATE
$3,000,000
DED I I RETENTION$
$
C WORKERS COMPENSATION
AND EMPLOYERS'LIABILITY Y/N
ANY PROPRIETOR/PARTNER/EXECUTIVE
OFFICER/MEMBER EXCLUDED? ❑
(Mandatory in NH)
N / A
1OWNR30600
!
12/31/2019
12/31/2020 1
X ' PER
STAT ER
E.L. EACH ACCIDENT
$1,000,(]0O
E.L. DISEASE -EA EMPLOYEE
__
$1,000,000
If yes, describe under
DESCRIPTION OF OPERATIONS below
E.L. DISEASE -POLICY LIMIT
$1,000,000
DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required)
The City of Ashland, its elected officials, officers & employees are included as Additional Insureds on the General Liability and Automobile Liability policies as
required by contract with respect to liability arising out of the operations of the Named Insured per terms and conditions of the above referenced policies.
Insurance coverage applies on a primary and non-contributory basis as required by contract per terms and conditions of the policies.
RE: Polydyne Clarifloc C-6286 (Li quid Polymer)
30 DAY CANCELLATION CLAUSE INCLUDED
CERTIFICATE HOLDER CANCELLATION
City of Ashland
20 East Main Street
Ashland, OR 97520
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISION
AUTHORIZED REPRESENTATIVE
Y"
l7 1988-2n14 ACORD r0RPORATIIAN All rinintc rcccrvcrl
ACORD 25 (2014/01) The ACORD name and logo are registered marks ofACORD