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HomeMy WebLinkAboutInsurance Certificate: Rubenstein's Contract Carpet LLC (2) • Client#:1785091 RUBENCON _ ACORD ,� CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DDIYYYY)10/11/2023 THIS CERTIFICATE IS ISSUED AS A 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(ies)must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement.A statement on this certificate does not confer any rights to the certificate holder in lieu of such endorsement(s). PRODUCER • CONTACT . NAME: Lori Andrews USI Insurance Services NW PHONE N,Ext):503 224-8390 FAx 825 NE Multnomah Suite 1500 E-MAIL (A/C,No): 610 362-8130 ADDRESS: Lori.Andrews@usi.com Portland,OR 97232 • • INSURER(S)AFFORDING COVERAGE NAIC# 503 226-3801 • 23434 A:Middlesex Insurance Company INSURED INSURER B:SAIF Corporation • 36196 Rubenstein's Contract Carpet LLC 160 Cleveland Street INSURER C Eugene OR 97402 INSURER D INSURER E: INSURER F: COVERAGES • CERTIFICATE NUMBER: 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 SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. LTR TYPE OF INSURANCE INSR WVD POLICY NUMBER POLICY EFF POLICY EXP LIMITS (MM/DD/YYYY) (MM/DD/YYYY) A X COMMERCIAL GENERAL LIABILITY A0148707004 03/15/2023 03/15/2024 EACHOCCURRENCE $1,000,000 CLAIMS-MADE X OCCUR I PREMISES(Ea occur ence) $500,000 I MED EXP(Any one person) $10,000 - PERSONAL&ADV INJURY $1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: • • GENERAL AGGREGATE $3,000,000 PRO- POLICY_ X JECT LOC PRODUCTS-COMP/OP AGG $2,000,000 OTHER: $ • • A AUTOMOBILE LIABILITY AO148707001 03/15/2023 03/15/2024 COa accidMBINEDent)SINGLE LIMIT 1,000,000 (E X ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED I AUTOS ONLY AUTOS BODILY INJURY(Per accident) $ HIRED NON-OWNED PROPERTY DAMAGE X AUTOS ONLY X AUTOS ONLY (Per accident) $ A xl UMBRELLA LIAB X OCCUR AO148707005 03/15/2023 03/15/2024 EACH OCCURRENCE '$10,000,000 EXCESS LIAB CLAIMS-MADE AGGREGATE $10,000,000 DED X RETENTION$0 $ B WORKERS COMPENSATION 794537 10/01/2023 10/01/2024 X STATUTE OTH- ER AND EMPLOYERS'LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE Y/N E.L.EACH ACCIDENT $1,000,000 OFFICER/MEMBER EXCLUDED? N/A (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $1,000,000 If yes;describe under ' DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $1,000,000 A Installation: A0148707003 03/15/2023 03/15/2024 Limit$1,000,000 Temp Storage/ • Limit$500,000 \ Transit Deductibles$1,000 • DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached If more space Is required) Re:All Projects When Required by Written Contract The City of Ashland and its elected officials,officers • and employees are included as additional insureds with primary and non-contributory wording and waiver of subrogation when required by written contract. . • . •CERTIFICATE HOLDER CANCELLATION Cityof Ashland SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE.WILL BE DELIVERED IN 20 East Main Street ACCORDANCE WITH THE POLICY PROVISIONS. Ashland,OR 97520-0000 • AUTHORIZED REEPRESE,NTATT�IVE ©1988-2015 ACORD CORPORATION.All rights reserved. ACORD 25(2016/03) 1 of-1 The ACORD name and logo are registered marks of ACORD #S42251066/M41723082 • • RYEZP This page has been left blank intentionally. A0148707004 COMMERCIAL GENERAL LIABILITY CG 20 01 04 13 2 • • THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. PRIMARY AND NONCONTRIBUTORY - OTHER INSURANCE CONDITION This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART PRODUCTS/COMPLETED.OPERATIONS LIABILITY.COVERAGE PART The following is added to the Other Insurance (2) You have agreed inwriting in a contract or Condition and supersedes any provision to the agreement that this insurance would be • contrary: primary and would not seek contribution Primary And Noncontributory Insurance from.any other insurance available to the additional insured. This insurance is primary to and will not seek contribution from any other insurance available to an additional insured under your policy provided that: (1) The additional insured is a Named Insured under such other insurance; and • • • CG 20 01 04 13 ©Insurance Services Office, Inc., 2012 Page 1 of 1 This page has been left blank intentionally. • POLICY NUMBER:A0148707005 COMMERCIAL EXCESS/UMBRELLA EU 70 91 05 15 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. AMENDMENT OF OTHER INSURANCE CONDITION . This endorsement modifies the coverage provided under the following: COMMERCIAL EXCESS/UMBRELLA COVERAGE PART With respect to the coverage provided by this endorsement, the provisions•of the Coverage Form apply unless modified by the endorsement. SCHEDULE Name Of Person Or Organization: Any Additional Insured as required by written contract or written agreement executed prior to loss • (If no entry appears above, information required to complete this endorsement will be shown in the Declarations as applicable to this endorsement.) The following is added to Paragraph H. Other (4) Affords indemnification and/or defense of Insurance of Section IV-Conditions: . the designated person or organization to• 1. This insurance is primary to and will not seek the extent permitted by law. contribution from any other insurance available 2. This condition does not apply to: to the person or organization shown in the a. Other insurance, not included in Paragraph 1. Schedule above, provided that such designated,. above, that 'may beavailable to the person or organization: designated person or organization outside of a. Is identified as an additional insured in the your written contract or agreement;or "underlying insurance"; b. Liability which: • b. Is _a Named Insured under such other (1.) May attach to the designated person or insurance;and • organization and is not assumed by your c. Has agreed with you in a written contract or written contract or agreement; or , agreement that: (2) Is assumed by the designated person or (1) Is. signed and effective prior to an organization under any other written "occurrence" to which this insurance contract assuming the obligations of applies; . another. . (2) This insurance would be primary and would not seek contribution.from such • other insurance identified in Paragraphs . 1.a.and 1.b.above; (3) Agrees to indemnify or defend the . designated person or organization for liability and damages covered by the "underlying insurance"; and EU 70.91 05 15 Includes copyrighted material of Insurance Services Office, Inc., Page 1 of 1 A0148707 with its permission. . . 04/27/2020 Middlesex Insurance Company I 00001 0000000000 20118 0 N 4051e411-42de-4b29-a216-5ded6242c814 This page has been left blank intentionally. • POLICY NUMBER: A0148707001 COMMERCIAL AUTO • CA 76 01 0615 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. DESIGNATED INSURED - PRIMARY AND - NONCONTRIBUTORY - COVERED_AUTOS LIABILITY COVERAGE ' This endorsement modifies insurance provided under the following: BUSINESS AUTO COVERAGE FORM MOTOR CARRIER COVERAGE FORM AUTO DEALERS COVERAGE FORM With respect to coverage provided by this endorsement, the provisions of the Coverage Form apply unless modified by this endorsement. This endorsement identifies person(s)or organization(s)who are"insureds"for Covered Autos Liability Coverage under the Who Is An Insured provision of the Coverage Form. This endorsement changes the policy effective on the inception date of the policy' unless another date is indicated. Named Insured: • Endorsement Effective Date: SCHEDULE '• • Name Of Person(s)Or Organization(s):: Information required to complete this Schedule, if not shown above,will be shown in the Declarations. A. Each person or organization shown in the B. Primary And Noncontributory Insurance Schedule is an "insured" for. Covered Autos Thisinsurance is primary to and will not seek Liability Coverage, but only to the extent that contribution from any other auto insurance issued person or organization qualifies as an "insured" to the person or organization in the schedule under the Who Is An Insured provision contained under your policy provided that: in: (1) Paragraph A.1. of Section II - Covered Autos (1) The person or organization is a Named Insured Liability Coverage in the Business Auto and under such other insurance; and Motor Carrier Coverage Forms;or (2) Prior to the "accident" you have agreed in (2) Paragraph D.2. of Section I - Covered Autos writing in a contract or agreement that this Coverages of the Auto Dealers Coverage insurance would be primary and would not Form. seek contribution from any other insurance available to the person or organization. CA 76 01 06 15 Includes copyrighted material of Insurance Services Office, Inc., Page 1 of 1 A0148707 with its permission. 03/14/2023 Middlesex Insurance Company 1 00001 0000000000 23073 0 N 88d0d581-bc9d-4fa6-9f77-b4c54dde6509 POLICY NUMBER: A0148707001 , COMMERCIAL AUTO CA 04 4410 13 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY: WAIVER OF TRANSFER OF RIGHTS OF RECOVERY AGAINST OTHERS TO US (WAIVER OF SUBROGATION) • This endorsement modifies insurance provided under the following: AUTO DEALERS COVERAGE FORM BUSINESS AUTO COVERAGE FORM MOTOR CARRIER COVERAGE FORM- i With respect to coverage provided by thisendorsement, the provisions of the Coverage Form apply unless modified by the endorsement. This endorsement changes the policy effective on the inception date of the policy unless another date is indicated below. Named Insured: Rubenstein's Contract Carpet LLC Endorsement Effective Date: 03/15/2023 SCHEDULE Name(s)Of Person(s)Or Organization(s): Any person or organization you are required to add as an additional insured under a written contract or written agreement in effect prior to any loss or damage. Information required to complete this Schedule, if not shown above,will be shown in the Declarations. The Transfer Of Rights Of Recovery Against ' Others To 'Us condition does not apply to the person(s) or organization(s) shown in the Schedule, but only to the extent that subrogation is waived ' prior to the "accident" or the "loss" under a contract with that person or organization. • CA 04 44 10 13 © Insurance Services Office, Inc., 2011 _ Page 1 of 1 A0148707 03/14/2022 Middlesex Insurance Company 1 00001 0000000000 22073 0 N d990c3d1-5159-4312-830d-28213592bd4f • POLICY NUMBER: sentry° ADDITIONAL INTEREST SUPPLEMENTAL DECLARATIONS The following additional interests apply to this policy. Any person or organization you are required to add as an additional insured under a written contract or written agreement in effect prior to any loss or damage PO Box 80544 Seattle, WA 98108-0544 CA 76 01 06 15 Designated Insured - Primary and Noncontributory - Covered Autos Liability Coverage • • • • • • CA 89 04 10 14 Page 1 of 1 A0148707 03/14/2023 Middlesex Insurance Company 1 00001 0000000000 23073 0 N 1db45c6a-1820-4804-9fbc-7858fadb21d6 This page has been left blank intentionally. z