HomeMy WebLinkAboutInsurance Certificate: Grayback Forestry Inc „-6 , •
ACCORD' `C-IR-TIFICATE:or LIABILITYiNRANCE
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THIS CERTIFICATE IS ISSUED A$A,'..4T.TEO.DF. INFORMATION ONLY'fi(0.4.„0-00(tP NO RIGHTS UPON THE CERTIFICATE HOLDER THIS-;
CERTIFICATE DOES: 0,07,4a:001047rly.04,OR;,,Isi04,1110ty:401014; EXTEND;013., ALTER THE p,-„OV*0A9,0 4F:FO00g4 BY THE
BELOW tiliko:tittItio*t ',.00-'1NotgiANag.,,OoE'k ot,gotoiTot -*,:„coNtRAdr 0.010.teN,THE (6siiih4-,iNO.htti(*),Mil-Otimitb!
REPRESENTATIVE OR okoopak,ANOlfit CERTIFICATE A0L0E0. ,
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IMPORTANTI)fth"e 0ificp10 11011$40 ADDITIONAL R4§v131),;;Iiwpsiiif6000;>.itlisojiaiimk)g)..r.rio;NAk.R-Ipu,Rp?;prpyipipps),9113q?-,ericlprgd..-
ittligfiddmicitC16AvAiliEtil iiiiii4iiiiii2,010•-fdiliii -J110 conditions of •601-4y;.oiitajei iioli**00y,040.0:,4 "fi',,'0060oirefip A statement on:
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Protectors 111,0.0140.06t40:1 --- -
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INSuRER(S)AFTORD1Na COVERAGE ;NAIOP
suFieit-A,OfilolDasualiiinturand6, 24074
INSURED: s°138Y21.ThaikEkEf::'Wetbhette'
qrAyl?acICEcirestryin a
Paj3.6k18$8, ;'14il' ORERV.:1411.0:1tiOrfil WI:DrIPDDIRSUrarlOte,0
Metlin,DR 97532430 INSURER ryi,Gmirtikstintifice,05
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iiisilftEf4"E TtleiCincinnatr Iris,utante:CO 10677,
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COVERAGES dERTIPICATE'ADMEt R •17,860I 680V
'; 13EIISJQNNUMBER:
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17Vis,IS,Icx:cg'}V,IF,r11%_ET0g.,P91IPAP:',9 „1.1.siALLW4Pi.g..JIP:1741._.PI-0ffl,2114:Vg BE ISSUE _P Tf? 11P,
,11N ,BER Viq\I ,•••
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INDICA,T. D. REQUIREMENTNNOTWITHSTANDING*12(, , '..4E.'N\ii):Pag,.(4)NPITIPX1.0 4Nif00N1...WT'PR.,:c,YI11_,„. .R 140PLIK.„NTNYITH RESPECT',.., . '1:94NHIPP'THIS
6-E-kfild'ATE7fOkY,",:n ,f.ib§6E0,bkf0P0e,:;Etkr:41-ktHt, iiOkM,0006140E0*ri'-i0 POLICIES ti,EpkiijriHLkEiN',1§-'SUBJECT TO Atli:rift TERMS',.:
ExcLUsioNg,ANzebbiturIDNS,DE'goLCH;,FIQLICIES,,,LIMIT.8:800WN'MWOOt BEEN REDUCED
INSR 'ADDICeUBR -,-, - - POLICTEFE pOLICrEXP,
TAW, iypE:OFiNSURArdE, i&so itihili POLICY,NUMBER INIMIDDLY-YY_YI.;:{/111M/DDNYYYY. liliiiiiiit:
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>.,,,,, X ,-COMMERciALGENERALLIABILITYy A st', .134,c0603811Et47, 1i1n020 1792921 :E...N04siCaiki0EifeE ' &t.,06000'0!
•,DArtigi.63-a12,ENT12, .
CLAIMSAVADE1 a'.? .OCCUR '
:PREMISES(Eib`ccuerence) , $4;.(100i000:
X 11ob'6Re' 15151 ,
, ,',mEttiiproisi,iiii6436iisify „ v5;000
0,08$01A71AAWfag.ii4Y: . 0100;000:
:060,C46kgOn''.*eliyiff X00.L.Tg,06-El*: ' .,:dgrkTrt:Ai_W&iit-0,Vil KlipAti.if4,
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POLICY X .Ella -LOC .,trp6R90,6.61:16sU7B:a,d47:67oRAGG ;,,21100,000j000°0°,'
OTHER
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Etr,wfoi0BILELiapl:igyi 'Y' r, .0O -1
1:tolobitr . f217i62-6 1/1/2021 , COMBINED E
, 9., LimIT -; -4,A;;040App,
EBA05774-63;; t 518/2020 ;518/2621 ,
b X.;,/,%friu,i-bi ' Ov,84002p„pdi 2/1/2020 1/1)2021 .;!3°D,ILY-''''JYRY'TOrP9F39'4. s'
OWNED SCHEDULED ,
BODILY INJURY(Per $
Atfrosb".**,, ,figiros, ., . -
IIIRED„. , ',NON;Olnited. . ',P.ROpERT,Y,D4MAG •
AliTOSAONLY-- AUTOS:ONLy T(Pdraceldent)
, , . —.,..„. ..,„ . -
X t)cess;Atio 14,666,66th . ,, , ,,
(AUTO POLLUTION.
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A!,,,, :UMBRELLA LiAs. X OCCUR gsogis8847, 11.11o2o 1.411'4;1 iti7,6'0:CCA:11*Et40,E:
, S-2,00;090
're , IM,4044.0 '1,1,11,4?0 _
X :,kithig'S'CiAlti' CLAIMS,MfDE „...4gcREptkTE„ . $'-.2;.ocko:Cf065
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„-OED . .:RETENTION , , , _.'Ad1bc.c-01,tkErle -. 40-1-dog's:toe_
*blikti4sto*ON giiiicA !PEROTH,
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13N,P.,WF0YEf.t,s.'LIABILITYwER.
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STATUTE
Wi9V0,i3pkifEi.',60/0,RWERiOkatti*rl ' , ',"E,t1.-EK6o,AcTei0EW;
OFFICERNEMSERIE?(OLUOfpt -' - .' NIA
04tid4-60,1141111" , - „, , ' E.L.DISEASEENEMPLOYEE Sr..
itiiis,416§doba'idcror
DESCRIPTION-OrOPERATIONSlieblio ,,,E1:::DISEASE,,POLIcyLINIIT, $.,-
D Auto Excess Liability p V,F062$909:1 .,,2/1/,?0?q 1/1402i •ge_qh oPcurrqncE.,, 13,..... )9
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mgp,pRIRT)oO;Of0,ERAttiliiiNO:1..6§i-r04*17*Iiipi..Es0t,ici? ifik4040:91*Ii.00 *4c!Y!,ei,,PiPyP.'040:0.,!, 471,°N; 54-P:71441,#,,i)
Tfie.--„ChiofA4hlin8„.:0*d66,,Ahd itk'-0166tod,,oftiorog;.-6ificerian:d.':pm`019ype*Os1:10itiphEiiln4red pei.,p61 icsiitn defs'01-nerit-,DO D4 11 (0404)1EiVre$Peet-yi
Q-oriff.atiostv,icesici.:46provided under contract..
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C:ERT,IFICATE HOLDER ,.,tAnicELLAtiON'
SfiOPLPARY,9 :'T/IPkOPYE,P5PRIPPiFPILPE§:flEA0c00:41EI., FPFW:
THE 0piRAti* DATE ii-O:plif, NOTICE WILL BE PO4v.pROp IN
. 1401.0.44#V.T01.*001.01*.010004,
:tityb, f A4liar!i3O ,
20-Ea§t.mairrst
Ashropti3OR 97512a ,,,keiiixti4.1.ii+i,i4Enikpy0-,,
I
. l,.0Erk2015*PPqr!TORP13MTI.P.01 'M'.:.06rit076k000-
04C.:))1P 25($16103) to,140 kr:1],o**000 l000,:oroogiOotosti in*koi-ipt -4,00,
•P; L.lMEl - 8140.8118`8884:1'
. toMMEKCIALOENERALLIABILITS%
',...0020.4,0 04 I:4,
• THIS 11:01-0EMEN:IT tHANES THEPOLICY. PLEASE READ fl-OARE,rifLift.
E • ow s • s 'to
ADDIT 'IONL iNSu RD.7—, NER LES, HEE R
CON TRACTORS SCHEDULED PERSON OR
ORG, ,AN:IZATION
orttiWthelbilowirig!
QPIVIIVIERG:IAL/gE,N1E13)10,LI Li Pc7.,V .1,31APFIPART
PRE PP "
,
'Lot"Atitiii(4 0:fOovetedOpetAtiOris
011,V OF ASH LANOt ALLMEPATION8
20 EAST MAIN STREET
• ASHLAN.Q, i.9,752:0: •
Infor-rffationfeCUTtartaltOMPlefetfiiig fitfOt thriwri boé1 ill bOIA Section II - inWeit*Clargtikini, !
Who Is An Insured is amended respect 40 the insurance afforded toi-k these
include as an additional insured tbe perSon(s):pr additiona insureds, the fotlowirig additional
orgenization(s),IShown in the Schedule, but only exclusions apply
with ireSj3eat to 10bility%fot!!OOdirc6itjotsg,vvOty Tris InSurence.':deet,'not'apijiy to "bodily injury" or
damage' "personal rand advertising injury' "properQ damage"occurring'aer
caused, inwhoIe or in patt, by
I All workincluding materials, parts or
1. YbuPacts or omissions or
NOMPPN tgrOP:,hgq; 09[ 711919A NAN such
t The acs onornisilbns oflthose acting on your works on the: project' (Other-•• than service),
, _
15017611t; OFfel5thi-S1 to be performed WO,
in
the P.00.9TMarIpPTO S/.90r-png0Tn.w9pOrtiono for on bhalf of the additional :at the
the raeditiOnal at location(s) 1000of the !I:W000 rsoperations :ti*'40101N
7Eidgi:dnOt06.1 ootnOletea'
HeWOVOr:; That portion of "your*ode" out of which the
inJüry or 0,011.000;005 has been ojg ó its
4. The insurance ,,afforded to such additional intended Use by any person or organization
ii7,fue.,o,00lits,:,'app.]idittbei-t6.-es...extent155.0ftnIte by other Viati iaboLf.*1!Loontraolop 01 subcuri1idc.,1oi
law,and engaed in performing. operatiors for
t .1fVoveredp!proVide463190?AddifiCn41 insured is princip:eles,Arp.p.rkpftriO:same project
rooked.-,Ot contract or et ireeterdlit ftie
insurance afforded to stiôh additionaj 14000
will not b Pc000,0r than ,th0f.:06.01T 1ou are
reogkeol by thg contract pr, egrgehlentii to
provici0;''f9r§gq6', 001i0.n4r1b,§mrgs*
tt 20 1044111 insurance sb.ivi000ffroe;i lió., 2611 Ngo,of
C i With respect to'the :ifOrdilow AffOi-40O to 160§-0 2 Avaiiatii6 Under the applicable Limits of
Insurance$hpvItri the Declarations,
additiOrialLih$pr000j, #10 following is added to
tddifin111, 3:Liir.iit0f-111rariq0 OhiPt1.0ff is less,,
If '.6,0)-4er0"g0,prOVI(100siil1noise001t;
required by a COfitfaet:,icifi aOrepteilti,ffifei most we 010400 'Limits of lr§!LITP.9,90 §„(10*,1,. in he
will '45qpn behalf of additional insured is the ‘Declarations
1. F30.cpitkd t3y,-tI1etdrittaet ar, 01-,eittierit;)tit-
Page 2 of'2 Itisijratie:0 ServicesQfficei 2012,
CO'20 1004431,
�. 4- cz-rozik
INSURANCE , LLC
May 20, 2020
TO: CERTIFICATE HOLDER
RE: GRAYBACK FORESTRY INC
PO Box 838,Merlin, OR 97532-0838
The attached certificate of insurance is to update and replace any prior certificate of
insurance for the 2020 policy terms. Please contact our office if you have any questions
regarding this updated form.
Thank you.
Ke itota t, Pori.
Kendall Pori, CIC
Commercial Lines Manager
Enc.
PO Box 4669,514 Crater Lake Ave,Medford,OR 97504
Phone(541)773-5358, Fax (541)772-1906, email infon,protectorsins.com