HomeMy WebLinkAboutInsurance Cancellation: COA PHILADELPHIA INDEMNITY INSURANCE COMPANY
1-877-438-7459
ONE BALA PLAZA, SUITE 100
BALA CYNWYD PA 19004
NOTICE OF CANCELLATION OF INSURANCE
Named Insured&Mailing Address: Producer:0003192
CITY OF ASHLAND BROWN&BROWN OF OREGON,LLC DBA
20 E MAIN ST BROWN&BROWN NORTHWEST
3256 HILLCREST PARK DR
ASHLAND OR 97520-1814 MEDFORD OR 97504-7657
Policy No.: PHPA082008
Type of Policy: PA :PARTICIPANT ACCIDENT COVERAGE
Date of Cancellation: 08/09/2021; 12:01 A.M. Local.Time at the mailing address of the Named Insured.
We are cancelling this policy. Your insurance will cease on the Date of Cancellation shown above.
- - � - - - - - IA
The reason for cancellation is NONPAYMENT OF PREMIUM 1601.00.
Within 30 days after receiving this notice, you may request a hearing before the director of the Department of
Consumer and Business Services.
Date Mailed: ,,
20t y of July ? 21
Named Insured
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't CITY OF ASHLAND
Mi 20 E MAIN ST
ASHLAND OR 97520-1814 JOAN HILLMAN
ORCCIONONPMNT
FORM#CC9697040R72000 07202021 MYNY
ODEN 3.0.21.06a Copy for Named Insured Page 1 of 1
ova PHILADELPHIA
INSURANCE COMPANIES
A Member of the Toldo Marine Group
One Bala Plaza,Suite 100,Bala Cynwyd,Pennsylvania 19004
0000949-0002019 SCOM 001 321818
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CITY OF ASHLAND
20 E MAIN ST
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