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HomeMy WebLinkAboutInsurance Certificate: RW Hays Co DBA Hays Oil Co. faxmodeml (2/4) 06/25/2021 12:41 : 37 PM -0700 • .-"'..."'INJ E(MM/DD/YYYY) A('(yR� ry CERTIFICATEOF LIABILITY INSURANCE DAT06!25/2021 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(les)must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED,subject to the terms end 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 NAMES Kim Wykes Elliott Powell Baden and Baker Inc. PHONE (503)445-8441 FAx 503 445-8481 An TSU Network Member Tar.be.Eat): (ac,No): ( ) ADDRESS:MAkwykeS@epbb.COm 1521 SW Salmon Street INSURERS)AFFORDING COVERAGE NAIC A Portland OR 97205-1783INSURER A: United States Flre Insurance Co. INSURED INSURER B: Certain Underwriters at Lloyds •RW Hays Co INSURER C: Endurance American Specialty Ins Co ' DBA:Hays Oil Company INSURER D: PO Box 1220 INSURER E: Medford OR 97501 INSURER F: COVERAGES CERTIFICATE NUMBER: 21-22 GUAuto/MTC/XS 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 SUBJECTTO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR ALIDLVIINSI WVD IMMIDDDYEFF/YYTY (MM POLICY LIMITS LTR TYPE OF INSURANCE POLICY NUMBER X COMMERCIAL GENERAL LIABILITY , 1,000,000 EACH OCCURRENCE $ CLAIMS-MADE,®OCCUR -- DAMAGE TO RtNrI D 1O(000 PREMISES(Ea oocunence) $ , MED EXP(Any one person) $ Excluded — A Y 5069020158 07/01/2021 07/01/2022 PERSONAL&ADV INJURY_$ 1,000,000 — GEN'LAGGREGATE LIMIT APPLIES PER: GENERALAGGREGATE $ 2,000,000 POLICY n jECT n LOC PRODUCTS-COMP/OPAGG $ 2,000,000 OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ 1,000,000 — (Ea accidarn) ANYAUTO BODILY INJURY(Per person) $ A X AUTOS ONLY _ AAUUTTOSSUt.ED 5069020158 07/01/2021 07/01/2022 BODILY INJURY(Per accident) $ X HIRED NON-OWNED \ PROPERTY DAMAGE AUTOS ONLY x AUTOS ONLY (Per accident) $ — X MCS-90 I X CA9948 Uninsured motorist $ 1,000,000 UMBRELLA LIAR EACH OCCURRENCE,,,. $ _ X occuR. 5 000,(00 B X EXCESS LIAR CLAIMS-MADE 21 RENMA2000005510037204 07/01/2021 07/01/2022 AGGREGATE • $ 5,000,000 DED I RETENTION$ $ WORKERS COMPENSATION ISTATUTE I 1ERH- AND EMPLOYERS'LIABILITY , YI N ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? n N/A EL EACH ACCIDENT $ (Mandatory In NH) EL DISEASE-EA EMPLOYEE $ II yes,describe under DESCRIPTION OF OPERATIONS below ' EL DISEASE-POLICY UM FT $ MotorTruck Cargo/ • $70,000 limit $1,000 Ded A/C Excess Uabllity 5069020158/EXC300000382504 07/01/2021 07/01/2022 $5,000,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Addflonal Remarks Schedule,may be attached If more apace I.required) - Re:Delivery of Fuel. CG 20 26 12 19 Is attached. CERTIFICATE HOLDER - CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN City of Ashland ACCORDANCE WITH THE POLICY PROVISIONS. 9.0 N Mountain Ave AUTHORIZED REPRESENTATIVE • Ashland OR 97520 61<{AM C J ®1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD faxmodeml ( 3/4) 06/25/2021 12:42:40 PM -0700 Bafg 907721 June 24, 2021 RW HAYS CO DBA HAYS OIL CO PO BOX 1220 MEDFORD,OR 97501 Re: Barrett Business Services, Inc. ("BBSI") Letter of Self-Insurance for Workers' Compensation Coverage As the named addressee of this Letter, your company's required workers' compensation coverage is provided through BBSI's state approved Self-Insured Workers' Compensation Plan by way of your co-employment contract with BBSI. Additional information is as follows: State: Oregon Workers'Compensation Limits: Employer Liability Limits: Self Insurance Certification#: 1068 Statutory $5,000,000.00 Each Accident - $5,000,000.00 Disease Coverage Limit by Gient $5,000,000.00 Disease; Each Employee Other Comments(place an"X"if applicable): © Named"Letter Holder": Elliott, Powell, Baden&Baker, Inc. 1521 SW Salmon St Portland, OR 97205 • © Other: This letter of self-insurance for workers'compensation replaces Acord form 25. Contract effective 7/1/17, renewed,through 6/30/22. Subject to 30 days'notice of cancellation. Additionally,BBSI's self-insured program is further supported by an excess workers'compensation insurance policy with ACE American Insurance Co.. Copy of certificate is available upon request. For additional information, please contact your local BBSI office at: MEDFORD (541)772-5469 3512 Excel Drive Suite 107 Very truly yours, Medford, OR 97504 MIS~i-.r-- , Efif0/0,11 Gary Kramer ' President and Chief Executive Officer doc:WM-2 faxmodeml (4/4) 06/25/2021 12 :43 : 19 PM -0700 POLICY NUMBER:5069020158 COMMERCIAL GENERAL LIABILITY CG 20 26 12 19 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - DESIGNATED PERSON OR ORGANIZATION This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Name Of Additional Insured Person(s)Or Organization(s): ANY PERSON OR ORGANIZATION THAT THE INSURED HAS AGREED BY WRITTEN CONTRACT OR WRITTEN AGREEMENT TO NAME AS AN ADDITIONAL INSURED AND EXECUTED PRIOR TO THE OCCURRENCE OF ANY LOSS. Information required to complete this Schedule, if not shown above, will be shown in the Declarations. A. Section II —Who Is An Insured Is amended to B. With respect to the Insurance afforded to these include as an additional insured the person(s) or additional insureds, the following is added to organization(s) shown in the Schedule, but only Section III—Limits Of Insurance: with respect toliabilityfor"bodily Injury", "property If coverage provided to the additional insured is damage or "personal and advertising injury" required by a contract or agreement, the most we caused, in whole or in part, by your acts or will pay on behalf of the additional insured is the omissions or the acts or omissions of those acting amount of insurance: on your behalf: 1. In the performance of your ongoing operations; 1• Required by the contract or agreement;or or 2. Available under the applicable limits of 2. In connection with your premises owned by or insurance; rented to you. whichever is less. However: This endorsement shall not increase the 1. The insurance afforded to such additional applicable limit"s of insurance. insured only applies to the extent permitted by law; and 2. If coverage provided to the additional insured is required by a contract or agreement, the insurance afforded to such additional insured will not be broader than that which you are required by the contract or agreement to provide for such additional insured. CG 20 26 12 19 ®Insurance Services Office, Inc., 2018 Page 1 of 1 Kxmodem1 ( 1/4) 06/25/2021 12:41 :08 PM -0700' * 1 This is a fax from pb8J insurance I±.Uk, E. Powell,hods-.*&Baker,loe, 1521 SW Salmon St. Portland, OR 97205 503-227-1771 503-274-7644 (main fax) r Date: 06/25/2021 12:40:26 PM #of pages: 3 ' • Fax#: 15414885320 Email: kwykes@epbb.com Subject: RW Hays Co DBA: Hays Oil Co Comments: • Kim Wykes Commercial Lines Account Manager ELLIOTT, POWELL, BADEN & BAKER, INC. 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