HomeMy WebLinkAboutInsurance Certificate: Kleinberg Tech Development & Technical Solutions, LLC 7TEJ(MM/DD/YYYY)
ACORD® CERTIFICATE OF LIABILITY INSURANCE7/2024
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 rights to the certificate holder in lieu of such endorsement(s).
PRODUCER CONTACT
NAME:
Hiscox Inc. PHONE $$$ 202-3007 FAX
5 Concourse Parkway E-MAIL
Ext: ) A/c No:
Suite 2150 ADDRESS: contact@hiscox.com
Atlanta GA, 30328 INSURER(S)AFFORDING COVERAGE NAIC#
INSURERA: Hiscox Insurance Company Inc 10200
INSURED
INSURER B
Kleinberg Tech Development&Technical Solutions, LLC INSURERC:
4667 Torrey Pines Dr.
Medford, OR 97504 INSURERD:
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.
INSR TYPE OF INSURANCE ADDL SUBR
POLICY EFF POLICY EXP
LTR POLICY NUMBER MMIDD YYY MMIDD YYY LIMITS
X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000
CLAIMS-MADE OCCUR DAMAGE TO RENTED PREMISES Ea occurrence) $ 100�000
MED EXP(Any one person) $ 5,000
A Y P102.683.257.2 12/01/2024 12/01/2025 PERSONAL&ADV INJURY $ 1,000,000
GEN'L AGGREGATE LIMIT APPLIES PER: GENERALAGGREGATE $ 2,000,000
X POLICY PELT LOC PRODUCTS-COMP/OPAGG $ S/T Gen.Agg.
OTHER: $
AUTOMOBILE LIABILITY COMBINEDSINGLELIMIT $
Ea accident
ANY AUTO BODILY INJURY(Per person) $
ALL OWNED SCHEDULED BODILY INJURY(Per accident) $
AUTOS AUTOS
NON-OWNED PROPERTY DAMAGE $
HIRED AUTOS AUTOS Per accident
UMBRELLA LAB OCCUR EACH OCCURRENCE $
EXCESS LAB CLAIMS-MADE AGGREGATE $
DED RETENTION$ $
WORKERS COMPENSATION PER OTH-
AND EMPLOYERS'LIABILITY Y/N STATUTE ER
ANYPROPRIETOR/PARTNER/EXECUTIVE 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 $
DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,maybe attached if more space is required)
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.
AUTHORIZED REPRESENTATIVE
@ 1988-2015 ACORD CORPORATION. All rights reserved.
ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD
AM HISCOX INSURANCE COMPANY INC. (A Stock Company)
H I SCOX PROm
30 North LaSalle Street,Suite 1760, Chicago, IL 60602
(646)452-2353
Insurance for Professionals
DECLARATIONS
NOTICE: YOUR POLICY CONTAINS CLAIMS-MADE LIABILITY COVERAGE. CLAIMS-MADE COVERAGE APPLIES ONLY TO
CLAIMS THAT ARE FIRST MADE DURING THE POLICY PERIOD OR DISCOVERY PERIOD, IF PURCHASED, AND REPORTED
IN ACCORDANCE WITH THE TERMS OF THE POLICY.
THE LIMIT OF LIABILITY AVAILABLE TO PAY DAMAGES WILL BE REDUCED AND MAY BE EXHAUSTED BY CLAIMS
EXPENSES. FURTHERMORE, CLAIMS EXPENSES WILL BE APPLIED AGAINST THE RETENTION.
PLEASE READ YOUR POLICY CAREFULLY AND CONSULT YOUR INSURANCE ADVISOR ABOUT ANY QUESTIONS YOU
MIGHT HAVE.
Broker No.: US 0002312 Indemnity Excess&Surplus Agency Inc.
Policy No.: MPL4644014.24 1915 NE Stucki Ave Ste 450
Renewal of: MPL4644014.23 Hillsboro, OR 97006
1. Named Insured: Kleinberg Tech Development&Technical Solutions LLC
Address: 4667 Torrey Pines Dr
Medford, OR 97504-9295
2. Policy Period: Inception Date: 11/03/2024 Expiration Date: 11/03/2025
Inception date shown shall be at 12:01 A.M. (Standard Time)to Expiration date shown above at
12:01 A.M. (Standard Time)at the address of the Named Insured.
3. General terms and PLP P0001 CW(07-19)
conditions wording: The General terms and conditions apply to this policy in conjunction with the specific wording
detailed in each section below.
4. Endorsements: E6020.4-War, Civil War, Cyberwarfare, and NCBR Exclusion Endorsement, E6017.3-Nuclear
Incident Exclusion Clause-Liability-Direct(Broad) Endorsement, E9035.3-Oregon Amendatory
Endorsement, and E6366.2-Privacy, Biometrics, and Cyber Incidents Clarification Endorsement
(PL)
5. Optional Extension Extended Reporting Period of 12/24/36 months at 75/150/225 percent of the annual premium.
Period:
6. Notification of Hiscox Claims
claims to: 5 Concourse Parkway, Suite 2150
Atlanta GA, 30328
Fax: 678-731-9501
Email: HiscoxClaims aD..Hiscox.com
Additional Notification NONE
requirements:
PLP D0001 CW(04/14) Page 1 of 3
RAC"'C hLe': �C hLhR';;t
HISCOX INSURANCE COMPANY INC. (A Stock Company)
AM 30 North LaSalle Street,Suite 1760, Chicago, IL 60602
(646)452-2353
H I SCOX PROm
Premium: $1890.00
Broker Fee: $175.00
Total: $2065.00
Insurance for Professionals
DECLARATIONS
7. Policy Premium: $ 1,890 Premium Allocated to TRIA: $0 State Surcharge: N/A
Miscellaneous Professional Liability Claims-made and Reported Coverage Part: PLPMPL P0001 CW
(06-14)
Covered Professional Services: Building Code Compliance Consulting services, for others for a fee
Professional Liability(PL): $ 1,000,000 Each Claim/$ 1,000,000 Aggregate
Defense of Licensing Proceedings: $25,000 Aggregate (Separate Limit)
Subpoena Assistance: $ 10,000 Aggregate (Separate Limit)
Retroactive Date: 11/03/2020
Retention: $7,500
PL Premium: $ 1,890
Endorsements: E6115.2-Financial Services Exclusions Endorsement
IN WITNESS WHEREOF,the Insurer indicated above has caused this Policy to be signed by its President and Secretary, but this
Policy shall not be effective unless also signed by the Insurer's duly authorized representative.
PLP D0001 CW(04/14) Page 2 of 3
RAC"'C hLe': �C hLhR';;t
HISCOX INSURANCE COMPANY INC. (A Stock Company)
Am 30 North LaSalle Street,Suite 1760, Chicago, IL 60602
TM (646)452-2353
H ISCOX
Insurance for Professionals
DECLARATIONS
0
President
�µ
Secretary
�6
Authorized Representative
Kevin Kerridge
October 7, 2024
Hiscox Inc.
PLP D0001 CW(04/14) Page 3 of 3
RAC"'C hLe': �C hLhR';;t
State Farm Mutual Automobile Insurance Company
PO Box 2358
Bloomington IL 61702-2358 A. State Farm
AT2 A-2310 A
KLEINBERG, JOHN & KELLY C p p p�pl p
4667 TORREY PINES DR AU'roIII°' III° II II ��
MEDFORD OR 97504-9295
PREMIUM PAID: $297.64
DO NOT IPAY.
Your premium is billed through the State Farm Payment Plan
State Farm Payment Plan Number: 1170330915
Your State Farm Agent
SHANE CUNNINGHAM INS AGCY INC
Policy Number: 172 7423-B01-37C Office: 541-772-3040
Policy Period: February 1, 2025 to August 1, 2025 Address: 820 S RIVERSIDE AVE
Vehicle: MEDFORD, OR 97501-7840
1999 FORD F350 SD If}ou have anew ordifferent car,have added any ddver,�orhavemoved,
Principal Driver: #ease contact your agent.
JOHN KLEINBERG Thank you for choosing State Farm.
Based on your driving record, you have our Accident-Free information from your check to make an electronic fund
Discount for preferred customers. transfer,funds may be withdrawn from your account as soon
When you provide a check as payment, you authorize us as the same day we receive your payment, and you will not
either to use information from your check to make a receive your check back from your financial institution.
one-time electronic fund transfer from your account or to
process the payment as a check transaction. When we use
Policy Number:172 7423-B01-37C Page number 1 of 5
Prepared December 10,2024
1004583 143562 202 01-15-2018
��I,H,3, ye-�bye l u I
Scan QR to sign up or visit
lhellllo g ��reeri ................
- statefarm.com/paperless
Enroll in paperless andyou'll get emails � ��I� _❑� ❑�
with links to do things like:
•download or print your auto ID card,
•pay your bill, �■
•or view documents,like your renewal.
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II",;°I1-i II C i,,,,II",;° I IN I"0 R 1V 1V AT 10 I
Review your policy information carefully. If anything is incorrect,or if there are any changes to your vehicle information, please
let us know right away.
Vehicle Identification
Vehicle Description Number(VIN) Who principally drives this vehicle? How is this vehicle normally used?
1999 FORD F350 SD 1 FTSW31 F7XEC64812 JOHN KLEINBERG,a married male,who To Work,School or Pleasure.
will be age 61 as of February 01,2025.
Other Household Vehicle(s)
Your premium may be influenced by other State Farm
policies that currently insure the following vehicle(s)
in your household:
2008 TOYOTA HIGHLANDER
The premium for this renewal was determined using an Premium Adjustment
annual mileage this vehicle is expected to be driven that Each year,we review our medical payments and personal
was developed from information we obtained or was injury protection coverages claim experience to determine
provided by you. The national average is more than 12,000 the vehicle safety discount that is applied to each make and
miles driven annually according to the U.S. Department of model. In addition,we review the comprehensive, collision,
Transportation. Please contact us if you expect your annual bodily injury and property damage claim experience
mileage to change over the next year. annually to determine which makes and models have
earned decreases or increases from State Farm's standard
rates. If any changes result from our reviews, adjustments
are reflected in the rates shown on this renewal notice.
I II II II",;°III 1I1Wl"ORNIATQN
Assigned Driver(s)
The following driver(s)are assigned to the vehicle(s)on this policy.
Age as of Marital
Name February 1,2025 Gender Status
JOHN KLEINBERG 61 Male Married
Other Household Driver(s)
In addition to the Principal Driver(s)and Assigned
Driver(s),your premium may be influenced by the
drivers shown below and other individuals permitted to
drive your vehicle. This list does not extend or expand
coverage beyond that contained in this automobile
policy. The drivers listed below are the drivers reported
to us that most frequently drive other vehicles in your
household.
KELLY C KLEINBERG
Policy Number:172 7423-B01-37C Page number 2 of 5
Prepared December 10,2024
A
Principal Driver&Assigned Drivers premium may be influenced by the information shown for
For each automobile, the Principal Driver is the individual these drivers.
who most frequently drives it.
Each driver is designated as an Assigned Driver on the
household automobile that they most frequently drive.Your
f, II',;1II A �1'-.,;1' AND t,,,II IM IITS See your policy for an explanation of these coverages.
A Liability
Bodily Injury 250,000/500,000
Property Damage 100,000 $94.80
P2 Personal Injury Protection
Includes Medical 25,000
Income Loss 3000/mo/yr $26.73
D 100 Deductible Comprehensive $52.31
G 250 Deductible Collision $81.48
H Emergency Road Service $6.43
R1 Car Rental&Travel Expense
$50 Per Day,$1,500 Max $8.61
U1 Uninsured Motor Vehicle
Bodily Injury 25,000/50,000
Property Damage 20,000 $27.28
'fatal Premium 297.64
If any coverage you carry is changed to give broader you the broader protection without issuing a new policy,
protection with no additional premium charge,we will give starting on the date we adopt the broader protection.
1Y1SCOtJNTS These adjustments have already been applied to your premium.
Multiple Line ✓
Multicar ✓
Vehicle Safety ✓
Accident-Free ✓
Annual Mileage ✓
Total Mlscdunts $361.9
t,V II II--N All �,m 11",;°S AIIN D I II S C 0 t„V IINT
AUTOMOBILE RATING PLAN -Applies to private you may qualify for our Accident-Free Discount. Once you
passenger cars only. qualify, this discount applies as long as there are no
Accident-Free Discount —Once your policy has been in chargeable accidents, and may even increase over time.
force for at least three years with no chargeable accidents,
(continued on next page)
Policy Number:172 7423-BOl-37C Page number 3 of 5
Prepared December 10,2024
A
Good Driving Discount - Newer policyholders who do not and receive accident surcharges. But if the accident is the
yet qualify for our Accident-Free Discount (available after first to become chargeable in nine years and this policy has
three years with no chargeable accidents) may already be been in force for at least that long, the Accident-Free
receiving a Good Driving Discount. This discount continues Discount will continue and no surcharge will apply. The
to apply until your policy qualifies for the Accident-Free surcharge for each accident depends upon the number and
Discount as long as there are no chargeable accidents and timing of the accidents, and each accident surcharge will
no new drivers. If you add new drivers, they must also remain in effect up to three years.
qualify in order for your Good Driving Discount to continue. Surcharges will be removed if the company is given
Chargeable Accidents - For new business rating, an satisfactory evidence that the driver involved is no longer a
accident is chargeable if it results in $750 or more of member of the household or will not be driving the car in the
damage to any property. For renewal business, an accident future. If that driver is insured on another State Farm policy,
is chargeable as of the date State Farm pays at least$750 his or her driving record will be considered in the rating of
(for accidents occurring on or after April 1, 1999) under the other policy.
property damage liability and collision coverages for an These discounts and surcharges do not apply to all
at-fault accident. coverages. For complete details, see your State Farm agent.
Surcharges — If there are chargeable accidents, you may
lose your Good Driving Discount or Accident-Free Discount
AIIII7II0INAI,,,, III1%I"ORIIATII0I'q
If any information on this renewal notice is incomplete or information regarding discounts or coverages, see your
inaccurate, or if you want to confirm the information we have State Farm agent or visit statefarm.com®.
in our records, please contact your agent. For additional
Nof6ice of Ihi uuraunce Ihifoirmaf6ion I1"racrf6ice
We may collect personal information from persons other than the individual or individuals applying for coverage. Such personal
information as well as other personal or privileged information subsequently collected may, in certain circumstances, be disclosed
to third parties without your authorization as permitted by law. If you would like additional information about the collection and
disclosure of personal information, please contact your State Farm agent.You may also act upon your right to see and correct any
personal information in your State Farm files by writing your State Farm agent to request this access.
Eir l�ottarnf Nof6ice IRea am°din Your IFlm° i uiu,Amr
State Farm works hard to offer you the best combination of price, service,and protection. The amount you pay for automobile
insurance is determined by many factors including:
• The coverage you have
• Where you live
• The kind of car you drive
• How the car is used
• Who drives the car
Any premium adjustment is reflected on this Auto Renewal. If you have any questions, please contact your agent.
Buyhng a new car? R irnem lber fay contact your age nd
When you buy an additional car or one that replaces a car already on your policy, you need to report the change to your agent
Promptly. Even though the dealership you purchased the car from may offer to notify your agent or insurance company, you, as
the named insured, are responsible for reporting all changes to your auto policy. By contacting your agent, you can help:
• avoid any complications or lack of coverage in the event of an accident or loss,
• avoid insurance verification problems with a lienholder, the police, or the department of motor vehicles, and
• ensure that you receive any new discounts you may be entitled to.
(continued on next page)
Policy Number:172 7423-B01-37C Page number 4 of 5
Prepared December 10,2024
A
Your current State Farm policy automatically provides certain coverages for a new or replacement car for up to a specified, limited
number of days after you take possession of the car. Please refer to your policy for the number of days that applies in your state.
If you have any questions about coverage for a newly acquired car, please contact your State Farm agent.
Disclaimer- This message is provided for informational purposes only and does not grant any insurance coverage. The terms and
conditions of coverage are set forth in your State Farm Car Policy booklet, the most recently issued Declarations Page, and any
applicable endorsements.
Policy Number:172 7423-B01-37C Page number 5 of 5
Prepared December 10,2024