HomeMy WebLinkAboutInsurance Certificate: Potelco, Inc. I Of 1
14341
ncoRo® CERTIFICATE OF LIABILITY INSURANCE DATE(MWDDfYYYY)
�i 5/1/2026 04/28/2025
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 beendorsed. 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 Lockton Companies,LLC ._ . PHONEc.ExL'r... ._
DBA as Lockton Insurance Brokers,LLC in CA
CA license#0F15767 E-MAIL
3657 Briarpark Dr.,Ste.700 - CBE ,
Houston TX 77042 _ INSURFR(S)AFFORDING COVERAGE_ NAICtf
(866)260-3538 INSURERA: Old Republic Insurance Company 24147
INSURED POTELCO,INC. INSURER B:A E Pro and Casually Insurance Company 20699
364742A QUANTA SERVICES COMPANY INSURER C:
14103 STEWART RD. INSURER D:
SUMNER WA 98390
INSURER E.
INS :
COVERAGES CERTIFICATE NUMBER: 12424201 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 CO OITI NS F SI•J,Q LICIES.LIMIT A AV PAID LAIM,
INSR ADDL UBF. POLICY EFF POLICYEXP
LTR TYPE OF INSURANCE INSD WVD POLICYNUMBER M/DDx"" MMfDD1YYYYI LIMITS
A X COINMERCIAL GENERAL LIABILITY M V�7 ZY 313093 5 05/01/202E 067�/ 2 EACH OCCURRENCE $ 5000,0�Q,W,
A MWZX 31309525 05/01/202c 06/01/202 MA GE TO -
4 CLAIMS-MADE OCCUR f`REMI $ 1 .000000 ..__._
$ Excluded
Y N MED FXP!Any one personl
PERSONAL&ADV INJURY $ 1,000000
GEN'LAGGREGATELIMITAPPLIES PER GENERAL AGGREGATE $ 5,000 000
POLICY JET ❑LC PRODUCTS-COMP/OP AGG $ 5.000.000
OTHER' $
A AUTOMOBILE LIABILITY MWTB 31309225. 05/01/202 06/01/202f EaaccideD SINGLE LIMtT $5,000,000
A X ANY AUTO MWZX313091 25 05/01/202F 06/01/202t BODILY INJURY(Per Person) $XXX)000C
OWNED 'SCHEDULED
X AUTOS ONLYLX
AUTOS Y N BODILY INJURY(Per accident) $ XXXXXXX
X HIRED NON-OWNED PROPERTY DAMAGEAUTOS ONLYAUTOS ONLY Peraccldenl $ XXXXXXX
sXXXXXXX j1
B UMBRELLA LIAR X OCCUR XEU G27972032010 05/01/202 06/01/202F EACH OCCURRENCE $ 5,000,000
X
EXCESS LIAB CLAIMS-MADE N NJ AGGREGATE $ 55,000,000
DEC) RETENTION$ s XXXXXXX
AND -......_... ..
WORKERS COMPENSATION rcr�
A EMPLOYERS'LIABILITY YIN MWC 313094 25 05/01/202 05/01/202 X `T T! I.
A ANF�PCEROPRIETOWDARTNENEXECUTIVr FN NfA N MWC 31309426 05/01/202 06/01/202E E.L.EACH ACCIDENT $ 1,000,000
(Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $ 1,000,000
DESCRIPTION OF OPERATIONS belm E.L.DISEASE-P )C. I n, $ 1 000",000 i
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,maybe attached if more space is required)
Re:All Operations General Liability And Auto Liability Policies Include The City Of Ashland, Oregon,And Its Elected Officials,Officers And Employees As An Additional
Insured When Required By Written Contract But Only As Respects Liability Arising Out Of Named Insured's Work For Additional Insured.
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
_...............
12424201 T53 P1 AUTHORIZED REPRESENTATIVE
The City O€Ashland,Oregon
Attn:Karl Ann Olson
90 N.Mountain Ave.
Ashland OR 97520
�1988- 015 ACORD UWORKTON.All rights reserved
ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD