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HomeMy WebLinkAboutInsurance Certificate: PacWest Machinery LLC AC Oo CERTIFICATE OF LIABILITY INSURANCE 09//08M/DD/YVVY) /20 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 CONSTIT&E 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 rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT NAME: Sentry Customer Service Sentry Insurance PHONE FAX 1800 North Point Drive A/C No Ext: 800-473-6879 A C. No):800-514-7191 Stevens Point,WI 54481 EMAIL ADDRESS: business products direct@sentry.com INSURER(S)AFFORDING COVERAGE NAIC# INSURER A:Sentry Select Insurance Company 21180 INSURED INSURER B: PacWest Machinery LLC INSURER C: 8207 S 216th St INSURER D Kent,WA 98032-1935 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER:4121619 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. I�TR TYPE OF INSURANCE NSR SWVD POLICY NUMBER (MMlDD/YYYY) (MM/D/YYYY LIMITS EACH OCCURRENCE $ CLAIMS-MADE ❑OCCUR DAMAGE TO RENTED $ PREMISES Ea occurrence) MED EXP(Any one person) $ PERSONAL 8 ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ POLICY ❑JECT LOC PRODUCTS-COMP OP AGG $ M' OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ (Ea accident) ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS HIRED NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY AUTOS ONLY (Per accident) P 1 1 $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED I I RETENTION$ $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY STATUTE ER ANY PROPRIETOR/PARTNER/EXECUTIVE Y/N E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? N/A (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $ it yes,describe under DESCRIPTION OF OPERATIONS below I I E.L.DISEASE-POLICY LIMIT $ Policy Aggregate Limit of Liability $100,000 A Cyber Liability and Data Breach Response N/A 2544074010 10/01/2025 10/01/2026 Retention $2,500 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached If more space Is required) CERTIFICATE HOLDER CANCELLATION City of Ashland,elected officials,officers,and employees SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE 20 E Main St THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Ashland,OR 97520-1814 ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE -- .. /47 ACORD 25(2016/03) Page 1 of 2 01988-2015 ACORD CORPORATION.All rights reserved. 2544074 The ACORD name and logo are registered marks of ACORD 09/08/2025 Sentry Select Insurance Company 3 00006 0000318 25251 N A 0 7f44417a-2dd8-45c3-bc72-3e47913a2cb7 0027020044383403710697520181420 �..� AGENCY CUSTOMER ID: x_xxxxx3567 ACC IR" LOC#: Iilh� - ADDITIONAL REMARKS SCHEDULE Page 2 of 2 AGENCY NAMED INSURED Marisa Jannaman PacWest Machinery LLC POLICY NUMBER 2544074010 CARRIER NAIC CODE Sentry Select Insurance Company 121180 EFFECTIVE DATE: 10/01/2025 ADDITIONAL REMARKS THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, FORM NUMBER: ACORD 25 FORM TITLE: Certificate of Liability Insurance ACORD 101 (2008/01) ©2008 ACORD CORPORATION.All rights reserved. 2544074 The ACORD name and logo are registered marks of ACORD 09/08/2025 Sentry Select Insurance Company 7f44417a-2dd8-45c3-bc72-3e47913a2cb7 0027020044383403710697520181420 ACO CERTIFICATE OF LIABILITY INSURANCE DATE D/VYYY) f.. os/o /zoz5 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 CONSTIT&E 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 poll y(ies) must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions o he policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder In lieu of such endorsement(s). PRODUCER CONTACT NAME: Sentry Customer Service Sentry Insurance PHONE FAX 1800 North Point Drive A/C No Ext: 800-473-6879 A/C No):800-514-7191 Stevens Point,WI 54481 EMAIL ADDRESS: business products direct s nt .corn INSURER(S)AFFORDING COVERAGE NAICK INSURER A:Sentry Select Insurance Company 21180 INSURED INSURER B: PacWest Machinery LLC INSURER C: 8207 S 216th St INSURER D: Kent,WA 98032-1935 INSURERE: INSURER F: COVERAGES CERTIFICATE NUMBER:4121619 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. INSR TYPE OF INSURANCE ADDL SUBR POLICY NUMBER POLICY EFF POLICY EXP LIMITS LTR INSR WVD (MM/DD/YYYY) (MM/DD/YYYY) EACH OCCURRENCE $ CLAIMS-MADE ❑OCCUR DAMAGE TO RENTED $ PREMISES(Ea occurrence MED EXP(Any one person) $ PERSONAL&ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ POLICY ❑ PECTRO- ❑ LOC PRODUCTS-COMP/OP AGG $ J OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ (Ea accident) ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED AUTOS ONLY AUTOS BODILY INJURY(Per accident) $ AUTOS ONLY AUUTOS ONES PROPERTY accidentDAMAGE $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ p $ WORKERS COMPENSATION STATUTE ERH AND EMPLOYERS'LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE Y/N E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? N/A (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $ h yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ �POLLUTIONI LIABILITY AGGREGATE LIMIT $1,000,000 A CLAIMS-MADE ❑OCCUR N/A 2544074007 10/01/2025 10/01/2026 POLLUTION INCIDENT LIMIT $1,000,000 LOCATION L MIT COVERED $100,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached If more space Is required) CERTIFICATE HOLDER CANCELLATION City of Ashland,elected officials,officers,and employees SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE 20 E Main St THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Ashland,OR 97520-1814 ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE /47 ACORD 25(2016/03) Page 1 of 2 ©1988-2015 ACORD CORPORATION.All rights reserved. 2544074 The ACORD name and logo are registered marks of ACORD 09/08/2025 Sentry Select Insurance Company 5 00006 0000318 25251 N A 0 20ea230a-8903-4e89-90fa-dfc04444e44a 0027020044383403711097520181420 AGENCY CUSTOMER ID: XXXXXX3567 AC"R" LOC#: `.� ADDITIONAL REMARKS SCHEDULE Page 2 of 2 AGENCY NAMED INSURED Marisa Jannaman PacWest Machinery LLC POLICY NUMBER 2544074007 CARRIER NAIC CODE Sentry Select Insurance Company 21180 EFFECTIVE DATE: 10/01/2025 ADDITIONAL REMARKS THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, FORM NUMBER: ACORD 25 FORM TITLE: Certificate of Liability Insurance ACORD 101 (2008/01) ©2008 ACORD CORPORATION.All rights reserved. 2544074 The ACORD name and logo are registered marks of ACORD 09/08/2025 Sentry Select Insurance Company 20ea230a-8903-4e89-90fa-dfc04444e44a 0027020044383403711097520181420 ACO® CERTIFICATE OF LIABILITY INSURANCE DATE/2025 D/VYYr) ��. os/oa zozs 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 CONSTIT&E 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 pollcy(les) 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 rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT NAME: Sentry Customer Service Sentry Insurance PHONE FAX 1800 North Point Drive A/C No Ext: 800-473-6879 A/C No):8 -514-7191 Stevens Point,WI 54481 EMAIL ADDRESS: busine s roducts direct@sentry.com INSURER(S)AFFORDING COVERAGE NAIC# INSURER A:Sentry Select Insurance Company 21180 INSURED INSURER B:Sentry Insurance Company 24988 PacWest Machinery LLC INSURER C: 8207 S 216th St Kent,WA 98032-1935 INSURER D: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER:4121619 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. INSR TYPE OF INSURANCE ADDL SUBR POLICY NUMBER POLICY EFF POLICY EXP LIMITS LTR INSR WVD (MM/DD/YYVY) (MM/DD/VYYY) X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $1,000,000 DAMAGE TO RENTED CLAIMS-MADE X OCCUR PREMISES(Ea occurrence) $500,000 MED EXP(Any one person) $5,000 A X 2544074006 10/01/2025 10/01/2026 PERSONAL&ADV INJURY $1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $3,000,000 X POLICY ❑PRO- ❑ LOG PRODUCTS-COMP/OP AGG $2,000,000 JECT OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $1,000,000 (Ea accident) X ANY AUTO BODILY INJURY(Per person) $ A AUTOS ONLY SAUTOS CHEDULED 2544074001 10/01/2025 10/01/2026 BODILY INJURY(Per accident) $ HIRED NON- WNED PROPERTY DAMAGE $ AUTOS ONLY AUTO ONLY (Per accident) X UMBRELLA LIAR X OCCUR EACH OCCURRENCE $8,000,000 A X EXCESS LIAB CLAIMS-MADE 2544074008 10/01/2025 10/01/2026 AGGREGATE $24,000,000 DIED I I RETENTION$ PRODUCTS-COMP/OP AGG $24,000,000 WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY STATUTE I I ER ANY PROPRIETOR/PARTNER/EXECUTIVE Y/N E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? N/A (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $ If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ Employee Benefits Occurrence Limit $500,000 Errors&Omissions Annual Aggregate Limit $1,000,000 A ERRORS&OMISSIONS 2544074005 10/01/2025 10/01/2026 Deductible $1,000 All Other Errors& Occurrence Limit $250,000 Omissions Annual Aggregate Limit $500,000 Deductible $2,500 B Employment Related Practices N/A 240 11 10/01/2025 10/01/2026 54740 Limit of Insurance $1,000,000 Liability Defense Expense Limit of Insurance $ DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached If more space Is required) Refer to attached CERTIFICATE HOLDER CANCELLATION City of Ashland,elected officials,officers,and employees SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE 20 E Main St THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Ashland,OR 97520-1814 ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE 147 •, ACORD 25(2016/03) Page 1 of 2 ©1988-2015 ACORD CORPORATION.All rights reserved. 2544074 The ACORD name and logo are registered marks of ACORD 09/08/2025 Sentry Select Insurance Company 7 00006 0000318 25251 N A 0 3cf72b7b-b562-4e24-b20a-f76194e3863a 0027020044383403711797520181420 �,.•� AGENCY CUSTOMER ID: xxxxxx3567 ACORU® LOC#: ADDITIONAL REMARKS SCHEDULE Page 2 of 2 AGENCY NAMED INSURED Marisa Jannaman PacWest Machinery LLG POLICY NUMBER 2544074006 CARRIER NAIC CODE sentry select Insurance Company 121180 EFFECTIVE DATE: 10/01/2025 ADDITIONAL REMARKS THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, FORM NUMBER: ACORD 25 FORM TITLE: Certificate of Liability Insurance General Liability GL Coverage provided is primary and non-contributory per the terms of endorsement CG 20 01. ACORD 101 (2008/01) ©2008 ACORD CORPORATION.All rights reserved. 2544074 The ACORD name and logo are registered marks of ACORD 09/08/2025 Sentry Select Insurance Company 3cf72b7b-b562-4e24-b20a-f76194e38638 0027020044383403711797520181420 POLICY NUMBER: 2544074006 COMMERCIAL GENERAL LIABILITY CG20101219 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - OWNERS, LESSEES OR CONTRACTORS - SCHEDULED PERSON OR ORGANIZATION This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Name Of Additional Insured Person(s) Or Organization(s) Location(s) Of Covered Operations City of Ashland, elected officials, officers, and 19255 NE Sandy Blvd Portland, OR 97230 employees Description: Paver repair and service Information required to complete this Schedule, if not shown above, will be shown in the Declarations. A. Section II - Who Is An Insured is amended to B. With respect to the insurance afforded to these include as an additional insured the person(s) or additional insureds, the following additional organization(s) shown in the Schedule, but only exclusions apply: with respect to liability for "bodily injury", This insurance does not apply to "bodily injury" or It damage" or This and advertising "property damage" occurring after: injury caused, in whole or in part, by: 1. All work, including materials, parts or 1. Your acts or omissions; or equipment furnished in connection with such 2. The acts or omissions of those acting on your work, on the project (other than service, behalf; maintenance or repairs) to be performed by or in the performance of your ongoing operations for on behalf of the additional insured(s) at the the additional insured(s) at the location(s) location of the covered operations has been designated above. completed; or However: 2. That portion of "your work" out of which the injury or damage arises has been put to its 1. The insurance afforded to such additional intended use by any person or organization insured only applies to the extent permitted by other than another contractor or law; and subcontractor engaged in performing 2. If coverage provided to the additional insured operations for a principal as a part of the same is required by a contract or agreement, the project. insurance afforded to such additional insured will not be broader than that which you are required by the contract or agreement to provide for such additional insured. CG 20 10 12 19 © Insurance Services Office, Inc., 2018 Page 1 of 2 2544074 09/08/2025 Sentry Select Insurance Company 9 00006 0000318 25251 N A 0 A0971F80-E760-4B82•ACCD-E23AAE777AA6 0027020044383403712597520181420 C. With respect to the insurance afforded to these 2. Available under the applicable limits of additional insureds, the following is added to insurance; Section III - Limits Of Insurance: whichever is less. If coverage provided to the additional insured is This endorsement shall not increase the required by a contract or agreement, the most we applicable limits of insurance. will pay on behalf of the additional insured is the amount of insurance: 1. Required by the contract or agreement; or �S Page 2 of 2 © Insurance Services Office, Inc., 2018 CG 2010 12 19 2544074 09/08/2025 Sentry Select Insurance Company A0971F80-E760.4B82-ACCD-E23AAE777AA6 0027020044383403712597520181420 IL 70 58 02 14 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. NOTICE OF CANCELLATION - CERTIFICATE HOLDERS This endorsement modifies insurance provided under the following: BUSINESSOWNERS COVERAGE FORM COMMERCIAL AUTOMOBILE COVERAGE PARTS COMMERCIAL PROPERTY COVERAGE PART CRIME AND FIDELITY COVERAGE PART COMMERCIAL INLAND MARINE COVERAGE PART COMMERCIAL GENERAL LIABILITY COVERAGE PARTS COMMERCIAL EXCESS/UMBRELLA LIABILITY COVERAGE FORM EMPLOYMENT RELATED PRACTICES LIABILITY POLLUTION LIABILITY COVERAGE ERRORS AND OMISSIONS COVERAGE FORM In the event we cancel this policy, we shall endeavor to also mail to the person(s)or organization(s) listed in the Schedule for this endorsement advance written notice of cancellation. This notification of cancellation of the policy is intended as a courtesy only. Our failure to provide such notification to the person(s)or organization(s)shown in the Schedule will not extend any policy cancellation date nor impact or negate any cancellation of the policy. This endorsement does not entitle the person(s) or organization(s) listed or described in the Schedule below to any benefit, rights or protection under this policy. Failure by us to provide this notice of cancellation to the person(s) or organization(s) listed or described in the Schedule below will not impose liability of any kind upon us. Any of these provisions that conflict with a law that controls the notice of cancellation of the insurance in this endorsement is changed by this statement to comply with the law. Schedule Person(s)or Organization(s) including mailing address: City of Ashland, elected officials, officers, and employees 20 E Main St Ashland, OR 97520-1814 All other terms and conditions of this policy remain unchanged. IL 70 58 0214 Page 1 of 1 2544074 09/08/2025 _ Sentry Select Insurance Company 11 00006 0000318 2S2S1 N A 0 A0971F80-E760-4B82-ACCD-E23AAE777AA6 0027020044383403712597520181420