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HomeMy WebLinkAboutInsurance Certificate: Hershman,Will DBA Bar Code Services State Farm at CityLine LJ PO Box 853925 Richardson, TX 75085-3925 00 StateFarme AT2 000997 1200 01. State Farm Fire and Casualty Company CITY OF ASHLAND Iq stock company with home offices;.in Bloomington; Illinois:: 90 N MOUNTAIN AVE IA ASHLAND OR.97520-2014 . . ., . - . O 0 I'llll11111III11ll"1111111,1111111111111111111,1iui'lllll1111111 . 0o , . • Renewal'. Declarations - . . Policy number: 97-CN-Y497-4 Effective date: February 1,2022 • - ' ' Policy period: 12 months Expiration date: February 1, 2023 . • . The policy period begins and ends at 12:01 am standard time at the premises location. OFFICE POLICY .1 , Automatic renewal -If the State Farm°policy:peri4is,shown as 12 months,;this:pglicy will be;r,enewed automatically subject;to the. _-, premiums,-rules-and forms j,ri effect for each,succeeding policy_period. If this policy is terminated, we will give you and the- _ Mortgagee/Lienholder written notice in compliance with the policy provisions or as required by law.` ' NAMED INSURED , . HERSHMAN, WILL DBA BAR CODE SERVICES ENTITY Sole Proprietorship-Individual . IMPORTANT MESSAGE(S) Notice - Information concerning changes in your.policy language is included. Please call your.agent if you have any questions. POLICY PREMIUM . This is not a bill.If an amount is due, thena separate statement-will be sent prior to the due date:The premium(s)shown below is the 12 months premium(s)for the characteristics of the policy'as described in this Declarations. . Total Premium:.$325.00 . _ Minimum Premium - . • , Discounts applied: Business Experience RatingRenewal Discount . Years in Business Business in Residence Premises .. . . . . • Policy Number:97-CN-Y497-4 Page 1 of 5 Prepared:November 24,2021 • ©Copyright,State Farm Mutual Automobile Insurance Company;2008, CMP Dec 3P OR.1 1009482 2005 153090 205 08-21-2021 CMP-4000 004451 0o e StatFarm') SECTION I-PROPERTY SCHEDULE • Location Location of described premises Limit of Insurance" Limit of Insurance* Seasonal increase- number Coverage A- Coverage B-Business Business Personal Property Building Personal Property 001 500 HELMAN ST No Coverage $23,400 ', -25%0' • ASHLAND OR 97520-1144 *As of the effective date of this policy, the Limit of Insurance as shown includes any increase in the limit due to Inflation Coverage. SECTION I-INFLATION COVERAGE INDEX(ES) • • Coy A-Inflation Coverage Index: N/A Cov B-Consumer Price Index: 273.6 SECTION I-DEDUCTIBLES BASIC DEDUCTIBLE $1,000 SPECIAL DEDUCTIBLES: „ Employee Dishonesty: $250 Equipment Breakdown: $1,000 Money and Securities: $250 . • Other deductibles may apply-refer'to policy. ' • SECTION I'_EXTENSIONS OF'COVERAGE-LIMIT OF INSURANCE EACH DESCRIBEDPREMISES The coverages and corresponding limits shown below apply separately to each described,premises shown in these Declarations, unless indicated by"See schedule", If a coverage'does not have:a corresponding limit shown below, but has"Included" indicated, refer to that policy provision for an explanation of that coverage. Coverage Limit of Insurance Accounts Receivable On Premises $50,000 '" ' ' Off Premises $15,000 `^ t Arson Reward $5,000' Back=up of Sewer or Drain $15,000 • Collapse Included • Damage to Non-owned Buildings from Theft,Burglary or Robbery Coverage B Limit Debris Removal 25%of covered loss , , ;• Equipment Breakdown Included Fire Department Service Charge $5,000 , , Fire Extinguisher Systems Recharge Expense ' ' $5,000 Forgery cc Alteration $10,000 Glass Expenses Included, • Policy Number:97-CN-Y497-4 Page 2 of 5 Prepared:November 24,2021 ©Copyright,State Faim MutualAutomobile Insurance Company,2008 ' GMP-4000 U 090 StateFant Coverage ' LimitoflnsuranóOYT , g; Increased Cost of Construction and Demolition Costs(applies only when buildings are insured on a 10% '-' • .; 14 replacement cost basis) Money Orders and Counterfeit Money $1,000 • § Money and Securities 0 csj On Premises $10,000 0 0 • Off Premises . , • $5,000 Newly Acquired Business Personal Property(applies only if this policy provides Coverage B-Business $100,000 ••• Personal Property) Newly Acquired or Constructed Buildings(applies only if this policy provides Coverage A-Buildings) $250,000 . • Ordinance or Law-Equipment Coverage • - • Included _ Outdoor Property • $5,000 • Personal Effects(applies only to those premises provided Coverage B-Business Personal Property) $5,000 • . Personal Property Off Premises $15,000 , • Pollutant Clean Up and Removal $10,000 Preservation of Property 0 30 days ., • •••• Property of Others(applies only tothose premises provided Coverage B','Buiiness Personal Property) $2,500 .• • ' Signs $2,500 Unauthorized Business Card Use $5,000 Valuable Papers and Records , -I • On Premises $50,000 • Off Premises • •• • . • .• , Water Damage, Other Liquids,Powder or Molten Material Damage Included •: •• - ' • SECTION I-EXTENSIONS OF COVERAGE-LIMIT OF INSURANCE-PER POLICY The coverages and corresponding limits shown below are the most we will pay regardless of the number of described premises Shown in these Declarations. • Coverage Limit of Insurance Dependent Property-Loss of Income $5,000 „ Employee Dishonesty • $10,000 . , Loss of Income and Extra Expense • 12 Months Actual Loss Sustained • Utility Interruption-Loss of Income $10,000 . , Policy Number:97-CN-Y497-4 Page 3 of 5 Prepared:November 24,2021 ©Copyright,State Farm Mutual Automobile Insurance Company,2008 CMP-4000 • 004452 • 090 State Farm' SECTION II-LOCATION SCHEDULE . -., . .. , Location Location of described premises ,. number . , 001 500 liELMAN ST . • i . . ASHLAND OR 97520-1144 SECTION II-LIABILITY , ..., . . Coverage , , Limit of Insurance Coverage L-Business Liability Per Occurrence , • . . Coverage M-Medical Expenses •- " - - •• - $5,000,Any One Person Damage to Premises Rented to You -- - - $300,009 , - - . .. .. ... . . • . Aggregate Limits Limit of Insurance . ' • Products/Completed Operations Aggregate , , '•, c 0 , , ,' ,•: ., • '$2,000,000 General Aggregate , . $2,000,000 ., Each paid claim for Liability Coverage reduces the amount of insurance we provide during the applicable annual period Please refer to Section II– Liability in the Coverage Form and any.attached-endorsements, Your policy consists of these Declarations,the BUSINESSOWNERS COVERAGE FORM shown below, and anrother forms and endorsements that apply; including those shown below as well as those issued subsequent to the issuance of this policy, . _ . FORMS AND ENDORSEMENTS ' - ' CMP-4100 Businessowners Coverage Form - .. CMP-4237.1 Amendatory Endorsement(Oregon) . , , • - CMP-4527 • Marijuana Exclusion- . . CMP-4551.1 Policy Endorsement • ,, • , CMP-4683.1 - Additional Insured-Owners,Lessees or Contractors(Blanket) - - CMP-4684.1 Additional Insured-Owners,Lessees or Contractors(Scheduled) - CMP-4703.1 Utility Interruption-Loss of Income - ' CMP-4704.1 Dependent Property-Loss of Income . •--- CMP-4705.2 • "Loss of.Income and Extra Expense • - - . . . _ . ..._ _ CMP-4706 Back-up of Sewer or Drain CMP-4709 Money and Securities • CMP 4710 Employee Dishonesty. • ,,,,, ,.: , , , , . , , ,,, , • ,-,•,•-• , , ,. , • • CMP-4819.1 Unauthorized Business Card Use ' ' , FD-6007 Inland Marine Attaching Declarations ' - , FE-3650 Actual Cash Value Endorsement FE-6999.3 Policyholder Disclosure-N6tice,of Terrorism Insurance Coverage SCHEDULE OF ADDITIONAL INTEREST(S) ', , _ .. . . . _. . . Interest type: • Owners,Lessees, or Confractors(Schedul ' ' . . . , . Endoriement number: CMP-4684.1 ., Loan number: , NIA' City of Ashland ' p . 90 N Mountain Ave. . — „• ,•_ . . , ., , Ashland OR 97520-2014 , . Policy Number:97-CN-Y497-4 ' ' Page 4 of 5 Prepared:November 24,2021 ©Copyright;State Farm Mutual Automobile Insurance Company,2008 ' . CMP-4000 , . . u 0 StateFarrne .. ,FULL NAMED INSURED . Named Insured: HERSHMAN, WILL DBA BAR CODE SERVICES This policy is issued by the State Farm'Fire and Casualty Company; " a PARTICIPATING POLICY You are entitled to participate in a distribution of the earnings of the company as determined by our Board of Directors in accordance co o • •with the Company's Articles of Incorporation, as.amended: . ' In Witness Whereof, the State Farm Fire and Casualty Company has caused,this policy to be;signed by its President and Secretary at • Bloomington, Illinois. . . President Secretary NOTICE TO POLICYHOLDER: ' For a comprehensive description of coverage and forms, please refer to your policy. • Policy changes requested before the "Date Prepared", which appear on this notice,"are effective on the,Renewal Date of'this.policy unless otherwise indicated by a separate endorsement, binder, or amended declarations..Any coverage forms attached to this notice • are also effective on the Renewal Date of this,polioy, . Policy changes requested after the"Date Prepared"will be sent to you as an amended declarations or as an endorsement to your policy. Billing for any additional premium for such changes will be mailed at a later date. If, during the past year, you've acquired,any valuable.property items, made any improvements to insured property,•or have any questions about your insurance coverage,'contact your State Farm agent. Please keep this with your policy. . Your coverage amount.... It is up to you to choose the coverage and limits that meet your needs. We recommend that you purchase a coverage limit equal to . the estimated replacement cost of your•structure. 'Replacement cost estimates are available from building contractors and 'replacement cost appraisers, or, your agent can provide an estimate from Xactware, Inc. using.information you,provide about your structure. State Farm does not guarantee that any estimate will be the actual future cost to rebuild your structre . Higher limits are, . available at higher premiums. Lower limits are also available, as long as the amount of coverage meets our underwriting requirements. We encourage you to periodically review your.coverages and limits With your agent and to,notify.us of any changes or additions to your structure. Policy Number:97-CN-Y497-4 , • Page 5 of 5 Prepared:November 24,2021 ©Copyright,State Farm•Mutual Automobile Insurance Company,2008 CMP-4000 ' 004453 State Farm at CityLine `J PO Box 853925 Richardson, TX 75085-3925 0CD 0 StateFarmo State Farm Fire and Casualty Company,,:, . „ ; CITY OF ASHLAND Astock company with home offices in Bloomington, Illinois "'.+ 90 N MOUNTAIN AVE ' ASHLAND OR 97520-2014 a a Inland Marine Attaching Declarations Policy number: 97-CN-Y497-4 Effective date:.February 1, 2022 Policy period: 12 months Expiration date: February 1, 2023 The policy period begins and ends at 12:01 am standard time at the,premises location. ATTACHING INLAND MARINE Automatic renewal-If the State Farm®policy period is shown as 12 months, this policy will be renewed automatically subject to the premiums, rules and forms in effect for each succeeding policy period. If this policy is terminated, we will give you and the MortgageelLienholder written notice in compliance with the policy provisions or as required by law. Annual policy premium: Included The above premium amount is included in the Policy Premium shown on the Declarations, FULL NAMED INSURED Named Insured: HERSHMAN, WILL DBA BAR CODE SERVICES Your policy consists of these Declarations, the INLAND MARINE CONDITIONS shown below, and any other forms and endorsements that apply, including those shown below as well as those issued subsequent to the issuance of this policy. FORMS,OPTIONS AND ENDORSEMENTS FE-6867 Inland Marine Amendment of Inland Marine Conditions FE-8739 Inland Marine Conditions FE-8743.1 Inland Marine Computer Property Form See below for schedule page with limits ATTACHING INLAND MARINE SCHEDULE PAGE Endorsement Coverage ', _ 'Limit of insurance Deductible amount Annual premium number FE-8743.1 Inland Marine Computer.Property Form $25,000 ' $500 Included Loss of Income and Extra Expense $25,000 Included Policy Number:97-CN-Y497-4 Page 1 of 2 Prepared:November 24,2021 ©Copyright,State Farm Mutual Automobile Insurance Company,2008 CIM Att Dec 3P OR.1 1009481 2002 153089 202 03-06-2021 FD-6007 004454 ' 0°0 St t r r Other limits and exclusions may apply refer to your policy. • • • • Policy Number:97-CN-Y497-4 • Page 2 of 2 Prepared:November 24,2021, ©Copyright,State Farm Mutual Automobile Insurance Company,2008. FD-6007 U CMP-4684.1 Page 1 of THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. .. y ADDITIONAL INSURED—OWNERS, LESSEES, OR CONTRACTORS (Scheduled) This endorsement modifies insurance provided under the following: BUSINESSOWNERS COVERAGE FORM co 0 SCHEDULE Policy Number: 97-CN-Y497-4 Named Insured: HERSHMAN, WILL DBA BAR CODE SERVICES 90 N Mountain Ave Ashland OR 97520-2014 ' Name And Address.Of Additional Insured Person Or Organization: City of Ashland 90 N.Mountain Ave Ashland OR 97520-2014 1. SECTION II —WHO IS AN INSURED of SECTION II —LIABILITY is amended to include, as an additional insured, any person or organization shown in the Schedule, but only: a. Ongoing Operations With respect to liability for "bodily injury", "property damage", or 'personal and advertising injury" caused by your ongoing operations for that additional insured and only to the extent that such "bodily injury", "property damage" or "personal and advertising injury" is caused by your negligence or the negligence of those performing operations on your behalf; or b. Products-Completed Operations To the extent that the liability for 'bodily injury" or"property damage" is caused by "your work" performed for that additional insured and included in the"products-completed operations hazard". 2. Any insurance provided'to the additionalinsured shall only apply with respect to a claim made or a"suit" brought for damages for which you are provided coverage. 3. Primary Insurance. The insurance-afforded the additional insured shall be primary insurance..Any insurance carried by the additional insured shall be noncontributory with respect to coverage provided by you. All other policy provisions apply. CMP-4684.1 155042 03-20-2019 ©, Copyright, State Farm Mutual Automobile Insurance Company,2018 Includes copyrighted material of Insurance Services Office,Inc.,with its permission. • 004455