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HomeMy WebLinkAboutAmended Insurance Certificate: Ouzel LLC State Farm at CityLine U PO Box 853925 Richardson, TX 75085-3925 QQ State Farm® AT1 000951 1200 01 State Farm Fire and Casualty Company CITY OF ASHLAND A stock company with home offices'in•Bloomington, Illinbis x. 20 E MAIN ST •••��. ASHLAND OR,97520-1814 • 0 J1IIIIlIIiuIillIIrilIiIIuIIIIIIIIIIIuuIIIIIIiillidIniIiIilIiIiI ' Amended Declarations. • . ' . ,., ,„_;, ,,,;,,,, ,!,,,,:,,,:.,-;,-, Policy number: 97-CP-R296-3 Effective date: August 20, 2021 Policy period: 12 months Expiration date:April 1, 2022 - The policy period begins and ends at 12:01 am standard time at the premises location, ,, i. OFFICE POLICY „ , 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•po_licy.period, If this policy is terminated, we will,give you and the MortgageelLienholder written,notice in compliance;`with the policy provisions or as required bylaw. NAMED INSURED • , OUZEL LLC .. ENTITY Limited Liability Company REASONS FOR DECLARATIONS ' ' Your policy is amended effective August 20, 2021 due to some recent policy changes you requested. Enclosed is a copy of your new endorsements, if any. - • - - ' - - • POLICY PREMIUM- . • This is not a bill.if an amount is due, then a separatestatement will be sent prior to the due date. The premium(s)shown below are for the policy period and policy characteristics as described in this Declarations. Change in premium: none Discounts applied: - . - . . • Business Experience.Rating . Renewal Discount . Years in Business • .. Policy Number:97-CP-R296-3 Page 1 of 5 Prepared:August 25,2021 . O Copyright,State.Farm Mutual Automobile Insurance Company,2008 1, CMP Dec 3P OR.1 1009482 2005 153090 205 08-21-2021 CMP-4000 003754 • , . • • • .. State Farrno .- . . . . . . . SECTION I-PROPERTY SCHEDULE - ... . ; — . . •. - . . , -•. - . . ., . .,L .1 . . Location . ' Location of described premises Limit of Insurance* . Limit of Insurance* ' ' Seasonal iriVease,- number Coverage A- Coverage B-Business Business Personal Property . ' • Building Personal Property 001 2800 BIDDLE RD . $492,700. $36;900 , ,, .25% . . 1. . . . MEDFORD OR 97504-4115 , *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: 190.6 Coy B-Consumer Price index: 260.4 . . ' SECTION I—DEDUCTIBLES. • . BASIC DEDUCTIBLE .. SPECIAL DEDUCTIBLES: - . . . Employee Dishonesty: $250 , . . • . , . Equipment Breakdown: $1,000 • Money and Securities: $250 • ' . Other deductibles may apply-refer to policy. ...i. .. .,:.,,-,-' , '',• SECTION I'--EXTENSIONS OF COVERAGE-LIMIT OF INSURANCE-:EACH DESCRIBED PREMISES . . . . . . 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 . . . •' ,."4 .; ,,,,, , , '. •, c;i,'-: ..;, Off Premises . $15,000 . . .. ,. , ,. . 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 or Alteration . $10,000 , • . Glass Expenses . Included Policy Number:97-CP-R295-3 - .. Page 2 of 5 Prepared:August 25,2021 . CO Copyright,State Faith Mutual Automobile Insurance Company,2008 • • CMP-4000 . . . . • . u • • oQ StateFarmo Coverage ,,:,r .+a, • • •r. '- " 9 Limit of Insurance-- RIIncreased Cost of Construction and Demolition Costs(applies only when buildings are insured on a 10% replacement cost basis) Money Orders and Counterfeit Money $1,000 , • Money and Securities - • •• - . - o i—rsj o On Premises $10,000 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 '"' " - • ' y-Included - Outdoor Property . -, • $5,000 Personal Effects(applies only to those premises provided Coverage B-Business Personal Property) $5,000 PersonalProperty Off Premises ' $15,000 Pollutant Clean Up and Removal . , $10,000: • _ Preservation of Property ' . 30 days - Property of Others(applies only to those premises provided Coverage B'-Business Personal Property) $2,500 '' Signs $2,500 . Unauthorized Business Card Use „ , $5,000 ., Valuable Papers and Records On Premises $50,000 ' ' Off Premises . -•• • •. .' •' - • $15,000 ` • 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.wilI 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-CP-R296-3 ,Page 3 of 5 Prepared:August 25,2021 ©Copyright,State Farm Mutual Automobile Insurance Cbmpany,2008 ' CMP-4000, ' ' . 003755 • •: 0o StateFarm® . SECTION II-LOCATION SCHEDULE ' ' Location Location of described premises. . , number 001 2800 BIDDLE RD .• , , • . MEDFORD OR 97504-4115 .' '` - - • ' • • • SECTION II-LIABILITY , , Coverage Limit of Insurance , Coverage L-Business Liability Per Occurrence., ,.. $2,000,000. Coverage M-Medical Expenses •. $10,000 Any One Person - Damage to Premises Rented to You ' $300,000' . • .. ' .. Aggregate Limits Limit of Insurance • • Products/Completed Operations Aggregate ,, • • , ,$4,000,000 • General Aggregate $4,000,000 Each paid claim for Liability Coverage reduces the amount of insurance we provide during the applicable annual period. Please'refer to S• • ection II'— Liability in the Coverage Form and any attached endorsements. - • Your policy consists of these Declarations,the BUSINESSOWNERS COVERAGE FORM'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 AND ENDORSEMENTS . • - ..- • CMP-4100 Businessowners Cov • erage Form _, . CMP-4237.1 Amendatory Endorsement(Oregon) • CMP-4527 Marijuana Exclusion . , : CMP-4561.1 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 °' -' A' '' CMP-4710 Employee Dishonesty ., CMP-4787 Waiver of Transfer of Rights or Recovery Against Others To Us ' CMP-4819.1 Unauthorized Business Card Use . • • FD-6007 Inland Marine Attaching Declarations . • FE-3650 Actual Cash Value'Endorsement -. FE-6999.3 — - Policyholder Disclosure Notice of Terrorism Insurance Coverage ' • ' ' - ' . SCHEDULE OF ADDITIONAL INTEREST(S). . ' • * , - Interest type: Owners,Lessees,or Contractors(Schedul • Endorsement number 'CMP-4684.1 , Loan number: - NIA` ' CITY OF ASHLAND ' • 20 E Main St ' Ashland OR 97520-1814 , Policy Number:97-CP-R296-3 page.4 of 5 • Prepared:August 25,2021 • ©Copyright,State Farm Mutual Automobile Insurance Company,2008 • ,f. CMP-4000 . . • u , • 090 StateFarm® • This policy is issued by the State Farm Fire and Casualty Company. r,. 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 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. • frite/( 4..A.C49.0 *111444d)111110WALL President Secretary • • • • • • • Policy Number:97-CP-R296-3 Page 5 of 5 Prepared:August 25,2021 ©Copyright,State Farm Mutual Automobile Insurance Company,2008 CMP-4000 • 003756 State Farm at CityLine u PO Box 853925 Richardson, TX 75085-3925 090 Chafe arms State Farm Fire and Casualty Company 1 CITY OF ASHLAND A stock company with home offices in Bloomington, Illinois r20EMAIN ST ASHLAND OR 97520-1814 • 0 0 0 Inland Marine Attaching g Declarations Policy number: 97-CP-R296-3 Effective date: August 20, 2021 Policy period: 12 months Expiration date:April 1, 2022 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 Mortgagee/Lienholder 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. 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 Other limits and exclusions may apply-refer to your policy. Policy Number:97-CP-R296-3 • Page 1 of 1 Prepared:August 25,2021 ©Copyright,State Farm Mutual Automobile Insurance Company,2008 CIM Att Dec 3P OR.1 1009481 2002 153089 202 03.06.2021 FD-6007 nna757