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HomeMy WebLinkAboutInsurance Certificate Amnd: Wild Rivers Surveying LLC (3) State Farm at CityLine U PO Box 853925 Richardson, TX 75085-3925 CO StateFarm@ AT1 000475 1200 01e State Parm Fire and Casualty'Company THE CITY OF ASHLAND A stock company with h"ome:officesdn•Bloomington 'Illinois EAt 20 E MAIN ST ASHLAND OR 97520-1814 IIIIIIIIIIIII111h1•hhhIIIII111111IIIIllIllli41111llthIh1116IIil (no Amended Declarations . iPc - -- : . ,,, c:-,:: ,: 1,.. )._ 1;1,:;c:;,". , , ? Policy number: 97-CN-X256-3 Effective date: September 10, 2020 Policy period: 12 months Expiration date: January 24, 2021. ' ' . ' The policy period begins and ends at 12:01 am standard time at the premises location. • BUSINESSOWNERS POLICY '' - ' , Automatic renewal -If the State Farn;i°policy,peripd;is:shown,as;12 months,.this policylwill._be renewed:automatically,,subject.to the -premiums,,rulesand 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 requi • red by law .` ... -. - - NAMED INSURED WILD RIVERS SURVEYING LLC . 3339 GREEN ACRES DR - _ - - - - CENTRAL POINT OR 97502-1413 ENTITY • , . Limited Liability Company . . - REASONS FOR DECLARATIONS Your policy is amended effective September 10,2020 due to some recent policychanges you requested;Enclosed"is a copy ofyour •` `..,. new endorsements, if any. POLICY PREMIUM This is not a bill.If an amount is due,then a 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: $379.00 ._ Discounts applied: ' Business Experience Rating Renewal Discount . Business in Residence Premises Policy Number:97-CN-X256-3 • Page 1 of 5 Prepared:September 19,2020 ©Copyright,State Farm Mutual Automobile Insurance Company,2008 ' CMP Dec 3P OR 1009482 2002 153090 202 06-05-2020 CMP-4000 001862 a ' ; StateFarm® 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 3339 GREEN ACRES DR No Coverage $26,700 •• ,, ¢ • , 25% CENTRAL POINT OR '97502-1413 *As of the effective date,of this policy, the Limit of Insurance as shown includes any increase in the limit dueto Inflation Coverage.. SECTION I—INFLATION COVERAGE INDEX(ES) Cov A-Inflation CoverageIndex: N/A Coy B-Consumer Price Index: 256.8 • SECTION I-DEDUCTIBLES BASIC DEDUCTIBLE , $500 SPECIAL DEDUCTIBLES: • Employee Dishonesty: $250 Equipment Breakdown: $500 Money and,Securities: $250 • Other deductibles may apply-refer to policy. SECTION I-EXTENSIONS OF COVERAGE LIMIT OF INSURANCE=EACH,DESCRIBED PREMISES The coverages and corresponding limits shown below apply separetely,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 • $10,000 Off Premises $5,000 Arson Reward $5,000 Collapse.. . r .• • 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 • $2,500 , Fire Extinguisher Systems Recharge Expense . $5,000 Forgery or Alteration $10,000' Glass Expenses ' Included • -Policy-Number:97-CN-X256-3 Page 2 of 5 Prepared:September 19,2020 ©Copyright,State Farm Mutual Automobile Insurance Company,2008 CMP-4000 L StateFarm Coverage Limit of Insurance j o-s."' -1r'' ' .`.:1, 1 • .,;5'; Increased Cost of Construction and Demolition Costs.(applies only when buildings are insured on a 10% •"" replacement cost basis) -- •- • . ..,. - • . VV-• - • .- Money Orders and Counterfeit Money - .. " $1,000 - -. sS Money and Securities - - •• OOn Premises . . _ - .. " - . $5,000 --- " co Off Premises $2,000' Newly Acquired Business Personal Property(applies only if this policy provides Coverage B-Business $100,000 , ' Personal Property) .v. . " - Newly Acquired or Constructed Buildings(applies only if this policy provides Coverage A=Buildings) •$250,000 : - - • • " - - Ordinance or Law'-Equipment Coverage '' Included ` • ' V Outdoor Property $5,000 Personal Effects(applies only to-those premises provided,Coverage B-Business Personal Property),.• $2;500 • ••. , Personal Property Off Premises $15,000 ,..; •.,,ya ,•, , 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 Valuable Papers and Records ' . . V V , On Premises $10;000 • . Off Premises $5,000 . Water Damage, Other Liquids,Powder or Molten Material Damage Included SECTION I-EXTENSIONSOP COVERAGE-LIMIT OF INSURANCE-PER POLICY. , The coverages and corresponding'lirnits shown below are the most we will payregardless of the number of'described premises shown in these Declarations.- Coverage r Limit of Insurance Employee Dishonesty • $5,000 . , Loss of Income and Extra Expense 12 Months Actual Loss Sustained , SECTION II-LOCATION.SCIjgpULE - . . : Location Location of described premises . number .. M1 " 001 3339 GREEN ACRES DR V CENTRAL POINT OR 97502-1413 v . Policy Number:97-CN-X256-3 Page 3 of 5 Prepared:September 19,2020 '©Copyright,State Farm Mutual Automobile Insurance Company,2008 • CMP-4000 ' 001863 . 0 0 StateFarm®. SECTION II-LIABILITY „ . ' Coverage ' •. • • • " Limit of Insurance' • ' ,, , Coverage L-Business Liability Per Occurrence V : . $2,000,000 - Coverage,M-Medical Expenses . • •. - - • $10,000 Any One Person • . - Damage to Premises Rented to You •- - • - . -$300,000 • 4- - Aggregate Limits Limit of Insurance Products/Completed Operations Aggregate . V. - .• ,: $5,000,000- General.Aggregate - $5,000,000 - 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 BUSINESSOWNERSCOVERAGE 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 Coverage 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-4705.2 Loss of Income and.Extra Expense CMP-4709' Money andSecurities . CMP-4710 Employee Dishonesty . . , CMP-4787 Waiver of Transfer of Rights of Recovery Against Others'To Us - CMP-4788 Additional Insured-Managers:or Lessors of Premises. . FD-6007 Inland Marine Attaching Declarations • . V FE-3650 Actual Cash Value Endorsement , FE-6999.2 Policyholder Disclosure Notice of Terrorism Insurance Coverage SCHEDULE OF ADDITIONAL INTEREST(S) .. • • .. Interest type: Owners,Lessees,or Contractors(Schedul Interest type: ' Owners,Lessees,or Contractors '(Schedul Endorsement number: CMP-4684.1 • , , ,:, % V. , . Endorsement number: CMP-4684.1 , . , • - . , Loan number: • .. N/A , V - Loan number: _ N/A City of Talent,Oregon .LTM Incorporated DBA Knife Riv . Po Box 445 PO Box 1145 talent OR.97540 , - _ Medford OR 97501-0231. . Interest type: Owners,Lessees,or Contractors(Schedul Interest type: Owners,Lessees,or Contractors(Schedul Endorsement number: CMP-468411 • - ' Endorsement number: CMP-4684.1 Loan number: N/A • ' Loan.number: . N/A , , V , ' • ' - ` " Jackson County . . .. ` . V _ - • " • Obeo Consulting Engineers'A Do ' '' ` " ' 10 S.Oakdale Ave. 920 Country Club Rd Ste 100B''..•�` ; );-,,• ' , { ,::.:... i,:,.: c Medford OR 97501 Eugene OR 97401-6089 Interest type:, Owners,Lessees,or Contractors(Schedul Interest type: Owne'rs,'Lessees,or Contractors(Schedul ' ' Endorsement number: CMP-4684.1 Endorsement-number: .CMP-4684.1 -- . - - ' - Loan number:• N/A - . Loan number: . N/A . Josephine County Oregon Department of Transport . 500 NW 6th st . . 3930 Fairview Industrial Dr SE ' Grants Pass OR 97526 Salem OR 97302-1166 - . Policy Number:97-CN-X256-3 • Page 4 of 5 Prepared:September 19,2020 ©Copyright,State Farm Mutual Automobile Insurance Company,2008 ' CMP-4000 u 0o StateFarm Interest type: Owners,Lessees,or Contractors(Schedul. Interest type: Owners,Lessees,or Contractors(Schedul ti Endorsement number: CMP-4684.1 Endorsement number: CMP-4684.i Loan number: N/A Loan number: N/A Skaar Construction Inc. The City of Ashland Po Box 1558 20 E Main St Auburn WA 98071 . Ashland OR 97520-1814 g Interest type: Owners,Lessees,or Contractors(Schedul Interest type: Managers or Lessors of Premises Endorsement number: CMP-4684.1 Endorsement number: CMP-4788 IL A Loan number: N/A Loan number: N/A The Ashland City Council The Medford Water COmmission a 20 E Main St 200 S Ivy St Ashland OR 97520-1814 Medford OR 97501-3100 This policy is issued by the State Farm Fire and Casualty Company. . 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, /f/fteit4.477,---- ) President V Secretary V Policy Number:97-CN-X256-3 Page 5 of 5 Prepared:September 19,2020 ©Copyright,State Farm Mutual Automobile Insurance Company,2008 CMP-4000 001864 State Farm at CityLine U PO Box 853925 Richardson, .TX 75085-3925 8 State Farm' State Farm Fire and Casualty Company THE CITY OF ASHLAND A stock company with home offices in Bloomington, Illinois 20 E MAIN ST ASHLAND OR 97520-1814 C C p �8 Inland Marine Attaching Declarations Policy number: 97-CN-X256-3 Effective date: September 10, 2020 Policy period: 12 months Expiration date: January 24, 2021 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 thispolicy. 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 MARINA@ 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-CN-X256-3 ' ' Page 1 of 1 Prepared:September 19,2020 ©Copyright,State Farm Mutual Automobile Insurance Company,2008 CIM Att Dec 3P OR 1009481 2001 153089 201 12-04-2018 FD-6007 001865