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HomeMy WebLinkAboutInsurance Certificate: WIlliams, Molly (2) { , -Ac R° VEHICLE'OR EQUIPMENT CERTIFICATEDATE(MM,DD,YYYY) �.� OF INSURANCE 104/07/2023 • - 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 I?RODUCER,AND THE CERTIFICATE HOLDER. This form is used to report coverages provided to a single specific vehicle or equipment.Do not use this form to report liability coverage provided to multiple vehicles under a single policy.Use ACORD 25 for that purpose. PRODUCER CONTACT StateFarm Russell P Brown Ins Agcy Inc NAME: Russell P Brown PHONE O 2581 W Main St Ea4lecdli Ext):_541-776-8488 FAX No): 541-776-8473 O ADDRESS: ruSsell@russeIlbrown.biz Medford,Or 97501 PRODUCER • CUSTOMER ID#: INSURER(S)AFFORDING COVERAGE NAIC 4 INSURED INSURER A: State Farm Mutual Automobile Insurance Company 25178 Williams,Molly INSURER B: IM.I. 1319 Harrisburg Drive INSURER C: El Medford,Or 97501 INSURER D: INSURER E: 7 DESCRIPTION OF VEHICLE OR EQUIPMENT YEAR MAKE I MANUFACTURER /, MODELBODY TYPE � VEHICLE IDENTIFICATION NUMBER 2019 Honda Odyssey Van 5FNRL6H73K9109359 DESCRIPTION ' VEHICLE/EQUIPMENT VALUE SERIAL NUMBER • COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: ' ' THIS IS TO CERTIFY THAT THE POLICY(IES)OF INSURANCE LISTED BELOW HAS/HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD(S)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 POLICY(IES)DESCRIBED HEREIN IS/ARE SUBJECT TO ALL THE TERMS.EXCLUSIONS AND CONDITIONS OF SUCH POLICY(IES). INSR ADDL POLICY EFFECTIVE POUCY EXPIRATION LTR !NERD TYPE OF INSURANCE POLICY NUMBER DATE(MMIDDIYYYY) DATE(MMIDDIYYYY) OMITS XI VEHICLE LIABILITY COMBINED SINGLE LIMIT $ A X 438 9758-1308-37 02/08/2023 ' 02/08/2024 BODILY INJURY(Per person) $ 100000 BODILY INJURY(Per accident) $ 300000 • PROPERTY DAMAGE $ 100000 GENERAL LIABILITY - ' EACH OCCURENCE $ • • OCCURRENCE GENERAL AGGREGATE $ CLAIMS MADE $ INSR LOSS POLICY EFFECTIVE POLICY EXPIRATION • LTR PAYEE TYPE OF INSURANCE POLICY NUMBER DATE(MMIDD/YYYY) DATE(MM/DD/YYYY) LIMITS I DEDUCTIBLE ' VEH COLLISION LOSS 0 ACV ❑AGREED AMT $ LIMIT • 0 0 STATED AMT S DED VEH COMP-I 1 VEH OTC \ 0 ACV 0 AGREED AMT S LIMIT ❑ 0 STATED AMT i DED EQUIPMENT , ❑ACV ❑AGREED AMT, BASIC BROAD $ LIMIT SPECIAL ❑RC ❑STATED AMT $ DED 0 REMARKS(INCLUDING SPECIAL CONDITIONS!OTHER COVERAGES)(Attach ACORD 101,Additional Remarks Schedule,If more space le required) ADDITIONAL INTEREST CANCELLATION Select one of the following: ' ' The additional Interest desatbed below hes been added to the policy(les)listed herein bypolicynumber(s). SHOULD ANY OF THE ABOVE DESCRIBEDIRATION DATE THERE POLICIES BE CANCELLED A reqquest has been submmad to add the"anal Interest described below to the poncy(lee) OF,NOTICE WILL BE DELIVERED IBEFORE THE N ACCORDANCE WITH THE POLICY PROVISIONS. listed herein try aollcv number(sl. VEHICLE!EQUIPMENT INTEREST: I I LEASED FINANCED DESCRIPTION OF THE ADDITIONAL INTEREST NAME AND ADDRESS OF ADDITIONAL INTEREST x ADDIONAL INSURED —"LOSS PAYEE . Certificate Holder: \ , LENDER'S LOSS PAYEE City of Ashland. LOAN I LEASE NUMBER . 51 Winburn Way Ashland,OR 97520 " AUTHORIZE. ;, P- f TATI _' I • ©1:' :2" ACO=' ORP,r ?'.All rights reserved. ACORD 23(2016/03) The ACORD name and logo are registered marks of ACORD ' • 1004361 142987.3 01-26-2016 A+ ..R VEHICLE OR EQUIPMENTDATE cMM,DDnY,Y, `� CERTIFICATEOF INSURANCE I oaio7/2ois 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. This form is used to report coverages provided to a single specific vehicle or equipment.Do not use this form to report liability coverage provided to multiple vehicles under a single policy.Use ACORD 25 for that purpose. PRODUCER CONTA , CT SfateFarm Agcy NAME: Russell P Brown i Russell P Brown Ins A C Inc PHONE (AIC,No,Ext): 541-778-8468 I q'jKC No: 541-776-8473 A 2581 W Main St EMAIL AODREss: russell@russelibrown.biz • Medford,Or 97501 PRODUCER CUSTOMER IDP: INSURED INSURER(S)AFFORDING COVERAGE NAM* INSURER A: State Farm Mutual Automobile Insurance Company, 25178 Williams,Molly INSURER B: r1 1319 Harrisburg Drive INSURER c Medford,Or 97501 INSURER D:• M INSURERE: DESCRIPTION OF VEHICLE OR EQUIPMENT J YEAR MARE/MANUFACTURER MODEL BODY TYPE VEHICLE IDENTIFICATION NUMBER 2012 , Ford Escape Utility 1FMCUOE72CKC19053 DESCRIPTION VEHICLE/EQUIPMENT VALUE SERIAL NUMBER J $ • , COVERAGES CERTIFICATE NUMBER: ' REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICY(IES)OF INSURANCE LISTED BELOW HAS/HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD(S)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 POLICY(IES)DESCRIBED HEREIN IS/ARE SUBJECT TO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH POLICY(IES). INSR ADD'L POLICY EFFECTIVE POLICY EXPIRATION " LTR INSRD TYPE OF INSURANCE • POLICY NUMBER DATE(MM/DDIYYYY) DATE(MMIDD/YYVY) LIMITS • Xj VEHICLE LIABILITY COMBINED SINGLE LIMIT $ A X 155 6519-C22-37F 02/27/2023 03/22/2024 BODILY INJURY(Per person) $ 100000 BODILY INJURY(Per accident) S 300000 • • PROPERTY DAMAGE $ 100000 GENERAL LIABILITY • EACH OCCURENCE $ OCCURRENCE GENERAL AGGREGATE $ CLAIMS MADE $ - INSR L093 POLICY EFFECTIVE POLICY EXPIRATION • ' LTR PAYEE TYPE OF INSURANCE POLICY NUMBER DATE(MM/DDIYYYY) DATE(MM/DD/YYYY) "LIMITS/DEDUCTIBLE VEH COLLISION LOSS 1 0 ACV ❑AGREED AMT $ LIMIT 0 0 STATED AMT $ DED VEH COMP I I VEH OTC 0 ACV ❑AGREED AMT $ LIMIT 0 0 STATED AMT $ DED EQUIPMENT ' — 0 ACV ❑AGREED AMT _ BASIC _ BROAD ❑RC El STATED AMT $ LIMIT SPECIAL 0 $ DED • REMARKS(INCLUDING SPECIAL CONDITIONS/OTHER COVERAGES)(Atteeh ACORD 101,Additional Remarks Schedule,If more apace la required) , ' ADDITIONAL INTEREST CANCELLATION Select one of the following: SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED The additional Interest described below has been added to the policy(les)listed herein by policy number($). BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE a request hoe been submtttedi to add the additional Interest described below to the policy(les) DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. bated hereto by Ocbcy numberrs). VEHICLE I EQUIPMENT INTEREST: I I LEASED FINANCED DESCRIPTION OF THE ADDmONAL INTEREST NAME AND ADDRESS OF ADDITIONAL INTEREST x ADDITIONAL INSURED LOSS PAYEE • Certificate Holder; LENDER'S LOSS PAYEE • City of Ashland LOAN!LEASE NUMBER 51 Winburn Way • fir/, Ashland,OR 97520 AUTHORIZE. `I PRE/TATIVE / — , • - ACORD 23 2016/03 a- 'O- ' JO .All rights reserved. ) The ACORD name and logo are registered marks of ACORD 1004381 142987.3 01-26-2016