HomeMy WebLinkAboutInsurance Certificate:: Noble Coffee Roasting LLC (2) f ® DATE(MMtDD/YYYY)
ACC>R O CERTIFICATE OF LIABILITY INSURANCE
12/18/2a25
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: Samantha L Musser
Hart Insurance Agency PHONE
PO Box 1240 A/C.
/C No Ext: (541) 779-4232 aC No:
E-MAIL
ADDRESS: smusser@hartinsurance.com
Grants Pass OR 9752$
INSURERS AFFORDING COVERAGE NAIC#
INSURER A:Allmerica. Financial Benefit In 41840
INSURED INSURER B:Hanover American Insurance Co 36064
Noble Coffee Roasting LLC
INSURER C:SAIF Corporation 36196
281 4th St INSURER D:
Ashland OR 97520 INSURERE:
(541) 326-1383 INSURERF:
COVERAGES SM CERTIFICATE NUMBER:Cert ID 33826 (4) 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 ADDL SUBR POLICY EFF POLICY EXP LIMITS
LTR TYPE OF INSURANCE POLICY NUMBER MM1DD MMIDD/YYYY
B X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000
DAMAGE TO RENTED
CLAIMS-MADE 1XI OCCUR Y OZ2D204742 04/13f202504/13/2026 PREMSES 6aoccurenca $ 340,000 -
MED EXP(Any one person) $ 5,000
PERSONAL&ADV INJURY $ 1,000,000
GENT AGGREGATE LIMIT APPLIES PER: GENERALAGGREGATE $ 2,000,000
X POLICY❑ PRO [ LOC PRODUCTS-COMPIOP AGO $
JECT
OTHER: $
COMBINED SINGLE LIMIT
AUTOMOBILE LIABILITY Ea accidentl $ 1,000,000
A X ANY AUTO AW2D204769 04/13/2025 04/13/2026 BODILY INJURY(Per person) $
OWNED SCHEDULED BODILY INJURY(Per accident) $
AUTOS ONLY AUTOS
HIRED NON-OWNED PROPERTY DAMAGE $
AUTOS ONLY AUTOS ONLY Per accident
I P I I i 1$
UMBRELLA LIAB OCCUR EACH OCCURRENCE $
EXCESS LIAB CLAIMS-MADE AGGREGATE
DED I I RETENTION$ $
WORKERS COMPENSATION X PER OTH-
C AND EMPLOYERS'LIABILITY YIN 776066 01/01/2026 01/01/2027� STATUTE ( ER
E.L.EACH ACCIDENT $ 1,000,000
ANYPROPRIETOR/PARTNERtEXECUTIVE
OFFICERlMEMBEREXCLUDED? NIA
(Mandatory in NH) E.L.DISEASE-EA EMPLOYEE S 1,000,000
if yes,describe under ( 1,000,000
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 is listed as additional insured where required by written contract per attached
form 391-1006.
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.
City of Ashland
20 E Main St AUTHORIZED REPRESENTATIVE
Ashland OR 97520
O 1988-2015 ACORD CORPORATION. All rights reserved.
ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD
Page 1 of 1
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ |TCAREFULLY.
BUUSUNESSOWNERS LIABILITY UTY SPECIAL BROADENING ENDORSEMENT
This endorsement modifies insurance provided under the following:
BUS|NESSOVVNERSCDVERAGE FORMSUM AARY OF COVERAGES Limits Page
1. Additional Insured by Contract,Agreement or Permit Included 1
2. Additional Insured—Broad Form Vendors Included 2
3. Alienated Premises Included 3
4. Broad Form Property Damage—Borrowed Equipment, Customers Included 3
Goods and Use of Elevators
5. Incidental Malpractice (Employed Nurses, EMT's and Paramedics) Included 3
6. Personal and Advertising Injury—Broad Form Included 4
7. Product Recall Expense Included 4
Product Recall Expense Each Occurrence Limit $25,000 Occurrence 5
Product Recall Expense Aggregate Limit $50,000 Aggregate 5
Product Recall Deductible $500 5
8. Unintentional Failure to Disclose Hazards Included 6
9. Unintentional Failure to Notify Included 6
This endorsement amends coverages provided under the Buaineeaowmem Coverage Form through new
coverages and broader coverage grants. This coverage is subject to the provisions applicable to the
Buoinaaeowmom Coverage Form, except au provided below.
The following changes are made to SECTION U — (2) Premises you own. runt. lease or occupy; �
LIABILITY: or
1. Additional Insured by Contract. Agreement or (3) Your mainhenanoo, operation or use of /
Permit equipment leased(oyou.
The following is added to SECTION U — b. The insurance afforded to such additional
LIABILITY, C.Who |mAnInsured: insured described above: �
Additional Insured by Contract, Agreement or (1) Only applies to the extent pomniUad by |
Permit law; and �
a. Any person or organization with whom you (2) Will not be broader than the insurance �
agreed ine written contract, written agreement which you are required by the contract, �
or permit to add such person or organization agreement or permit to provide for such �
as an additional insured on your policy iaan additional insured.
additional insured only with respect to liability (3) Applies on u primary basis if that is .
for "bodily injury", "property dammge^, or required by the written contract, written �
''peneono| and advertising injury' oauoed, in agreement nrpermit. �
whole or in part' by oromioeiuna. or
(4) Will not be broader than coverage
the acts or omissions of those acting on your
behalf, but only with respect to:
p»»vided�oanyothurinour�d�
(1) "Your work" for the additional insured(s) (5) Does not apply if the "bodily injur/',
designated in the contract, agreement or
^prope�y damage" or "personal and
permit; advertising irjury' is otherwise excluded
� from coverage under this Coverage Pad.
including any endorsements thereto.
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(3) Any physical or chemical change in the The most we will pay on behalf ofthe vendor
product made intentionally by the vendor; for a covered claim is the lesser of the amount
(4) Repaokaging, unless unpacked oo|d ofinmunanoe
solely :
the purpose of inspection, demonstration, 1. Required by the contract or agreement
baohng, or the substitution of parts under described in Paragraph a.; or
instruction from the manufacturer, and 3. Available under the applicable Limits of
then repackaged in the original container; Insurance shown in the Declarations;
(5) Any failure to make such inopeo(ion. This endorsement shall not increase the �
acUuatmentm, tests or servicing as the applicable Limits of Insurance shown in the
vendor has agreed to make or normally Declarations.
undertakes to make in the usual course of
3 Alienated Premises
busineosinoonneotionwithiheoa|eofthe '
product; SECTION |U — LIABILITY, B. Exclusions, 1.
(G) Demonstration, installation, servicing or Applicable To Business Liability Coverage h.
Damage to Pro�e�y, paragraph �U is n*p|uoed
repair operations, except such operations '
performed at the vendor's premises in by the following:
connection with the sale ofthe,produot; (2) Premises you aa||, give away or abandon. if
(7) Products which after distribution or su|* the''pnope�ydamage"arises out of any pa�of
'by you, those pn*miaoy and occurred from hazards
have been labeled or or
' that �en* known by you or should have
used auaoontainer. padoringn*di�ntof '
any other thing or substance by or for the reasonably been known by you, at the time the
vendor; pnope�ywas transferred orabandoned.
' Proper
ty Damage — Borrowed(0) "Bodily injury" or "property damage ' Broad Form
arising out of the po|o negligence of the Equipment, Customers Goods, Use of
vendor for its mmm acts or omissions or Elevators
those of its employees or anyone else o. The following is added to SECTION 11 —
acting on its behalf. However, this LIABILITY, B. Exclusions, 1. Applicable To
exclusion does not apply to: Business Liability Coverage, k. Damage to
(m) The exceptions contained within the Property:
exclusion in subparagraphs (4) or Paragraph (4) does not apply to "property
abova; or demaUe" to borrowed equipment while at a
(b) Such inopootionm, adjustments, tests ]oboiie and not being used to perform
or servicing ao the vendor has agreed operations.
to make or normally undertakes to Paragraph (3), (4) and (G) do not apply to
make in the usual course ofbusiness, "property damage" k/ "customers goods"while
in connection with the distribution or on your premises nor to the use ofelevators. �
sale nf the products. b' For the purposes of this endorsement, the �
(Q) "Bodily injury" or "property damage" following definition is added to SECTION 11 — �
arising out of an "occurrence" that took L|/\8|L|TY, F. Liability and Medical �
place before you have signed the contract Expenses Definitions: �
or agreement with the vendor 1 "Customers goods" means property o� ^
� . uo moru goo e �
(10)To any person or organization included as your customer on your premises for the
an insured by another endorsement purpose ofbeing: �
issued by us and made part of this a. Worked on; or
Coverage Part.
b. Used in your manufacturing process.
(11)Anyinounad person or organization, from .
whom you have acquired such products, c. The insurance afforded under this provision is !
or any ingrudiont, part or unntminer, excess over any other valid and collectible `
entering into, accompanying or containing property insurance (including deductible)
available to the insured whether primary,
'
d. With respect to the insurance afforded to excess, contingent uron any other basis.
these vendura, the following is added to 5. Incidental Malpractice — Employed Nurses,
SECTION U — LIABILITY, D. Liability and EK0T'm and Paramedics
Medical Expense Limits ofInsurance: SECTION U — LIABILITY, C. Who hsAnInsured,
' paragraph 2.o.(1)(d) does not apply to a nurse,
381-10000810 Includes copyrighted materials of Insurance Services Offices,Inc.,with its permission. Page 3ofS
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peu!edm| jo qjo8h 's4onpcud 10 ||aoeH 'o o!p*meund jo ua!o!uqoel |eo!pom Aoumbbeme
c. The following is added to SECTION 0 — a deductible amount you shall promptly
LIABILITY, D. Liability and Medical reimburse ue for the part of the deductible
Expenses Limits ofInsurance: amount wmpaid.
Product Rooa|| Expense Limits of The Product Recall Expense Limits of
Insurance Insurance apply separately to each
a. The Limits of Insurance shown in the consecutive annual period and to any
SUMMARY OF COVERAGES of this remaining period of |eaa than 12 monthm,
endorsement and the rules stated below starting with the beginning of the policy period
shown in the Declarations, unless the policy
fix the most that me will pay under this '
Product Recall Expense Coverage period is extended after issuance for an
regardless of the number of: additional period o/ |uao than 12 months. In
that case, the additional period will bmdeemed
(1) Insureds; port of the last preceding period for the
(3) "Covered Recalls initiated; or purposes of determining the Limits of
(3) Number of"your products"withdrawn. Insurance.
d The following is added to ����T|C}N U| —
b The Product R*c�|| Expense Aggregate '
' L|/\�|L|�Y' E.� Liability and Medical
Limit is the most that we will reimburse
u for the sum of all "product recall Expense General Conditions, 2. Duties in
youexpenses"incurred for all"covered recalls" the Event ofOccurrence, Offense, Claim or
initiated during the policy period. Suit:
o' The
You must see ho it that the following are done
in the event of an actual or anticipated
is the most we will pay in connection with
"covered veoaU^ that may result in "product
any one defect or deficiency.
recall expense":
d. All "product recall expenses" inconnection
with substantially the same general (1) Give uo prompt notice nf any discovery or
harmful condition will bmde*noodb` arise notification that "your product" must be
vviihdmvvn or raoo||ad Include e
out ofthe same defect orde�oienoyand �
description of "your product" and the
considered one^oouumence.
. reason for the withdrawal orrecall;
e. Any amount reimbursed for"product recall
expenses" in connection with any one (2) Cease any further ne|ooee. shipment,
^000urrenoa^will reduce the amount ofthe consignment or any other method of
Product Recall Expense Aggregate Limit distribution of like or similar products until
it has been determined that a|| such
available for reimbursement of "product
recall expenses" in connection with any products are free from defects that could �
other defect ordeficiency.
baa cause of loss under this insurance.
t If the Product Recall Expense Aggregate a. For the purposs of this endorsement, the �
Limit has been reduced by reimbursement following definitions are added to SECTION O
. — LIABILITY, F. Liability and Medical
of^produdrecaUuxpunaeo ioanamount '
that is |ooa than the Product Recall Expenses Definitions: �
Expense Each 0oournenoa Limit, the 1. "Covered recall" means a reoo|| made �
remaining Aggregate Limit is the most that necessary because you or a government �
will be available for reimbursement of body has determined that a known or �
/
"product recall expenses" in connection suspected defeoi, deficiency, inadequooy,
with any other defect ordeficiency. or dangerous condition in "your product" �
g. Product Recall Deductible
has nuou}tmd or will result in "bodily injury"We will only pay for the amount of "property
"product recall expenses" which are in 2' "Product recall expanae(a)"means: .
excess of the $500 Product Recall a. Necessary and reasonable expenses �
Deductible. The Product Recall Deductible for �
applies separately to each "covered (1) Communioations, including radio
recall". The limits of insurance will not be or television announcements or
reduced by the amount of this deductible. printed advertisements including �
We may, or will if required by law, pay all etaUonary, envelopes and
or any pad of any deductible amount, if postage;
applicable. Upon notice of our payment of
891-10060815 Includes copyrighted materials cx Insurance Services Offices, mu.'with its permission. Page 5uf6
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