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Home My WebLink AboutInsurance Certificate: Bell Hardware of Medford, Inc. DATE(MMIPOIYYYY) -- ACOFL] CERTIFICATE OF LIABILITY INSURANCE 316r2026. . 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 ROES 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 pol)cy(fes)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 - _ -.........._ ...._ .. �Na E; I4121is6a Castaneda - Hub International Northwest,LLC Ptior+e 2300 Madison Street 54t-882-55d7 _ Arc xd:541-894-OP62 Klamath Falls OR 97603 ut s rrlatissa i as .ubinternationo.coin... INSURFR(SI AFFORDING COVERAGE ... ......... :. NAICS INSURER A.Charter Oak Fire insurance Company 25615. . INSURED OELLHAR-01 INSURER B:Travelers Property CasuaU Company of America 25674.............. Bell Hardware of Medford, Inc. 1160 Knutson Ave. INs17RERC:The Travelers(ndemn!V Company 25658 _ Medford OR 97504 INSURERD: INSURER E: EEd ........ ... ........ ------_. --- -.__ INSUR€RF: COVERAGES CERTIFiCAT'i NUMBER:1289195663. REVISION.NUMBEft. 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. LSR AD L� a ........ POLICYEFF POLICY _ .... ... .LIMITS TYPE OF INSURANCE .. -- POI.ICYNUMBEIi MID woorYYYY . C X COMMERCIAL GENERAL LIABILITY Y 630OT716377 211/2026 VV2027 EACH OCCURRENCE $1,000,000. CLAIMS-MADE..�OCCUR A - -PR !.F ...._... $30D,000 ..... MED EXP(Anyone person): $5.000 pEcRSONAL SADV INJURY $1,000,000 GEML AGGREGATE LIMITAPPLIESPER: GENERAL AGGREGATE.. $2,000,000 POLICY PRO- PRODUCTS-COMPIOPAGG $2,000000XJT LOC . S OTHER: : ..... :... ... Y 21t 12026 2/112027 :. ;-.. rN 5I L LINT $- 1,000r000A AUTOMOBILE LIABILITY 3 G X ANY AUTO BODILY INJURY(Per person) S OWNED SCHEDULED BODILY INJURY(Per Occident),S AUTOS ONLY AUTOS ' - x HIRED -X NON-OWNED ...E danl AMAGE �5 AUTOS ONLY AUTOS ONLY . S $ UMBRELLALIAB X OCCUR Y EXOT742254 2111202b 2I112027 EACH OCCURRENCE S 5.000.000 X; ExCEssLIAO CLAIMS-MADE AGGREGATE SS.OI10,400 DED I I RETENTIONS ... ... - ...._..... -. S . WORKERS COMPENSATION _- -_ PER CH. .. AND EMPLOVERS'LLABILITY YIN TA- E.. ANWROPRIETOMPARTNERIEXECUTIVE ❑ NIA E_L,EACH ACCIDENT _ S OFFICERIMEMBEREXCLUDED? - - (MandatoryInNH) E.L,DISFASE-EA EMPLOYEE S Iry��ss,,describe under DE SCRIPPONOFOPERATIONSbalow E.L:DISEASE-POLICY LIMIT S C InstallaitonFloater 630D-HIS377 2/112026 2/1/2027 Lirttit 260,000 - DESCRIPTION OF OPERATIONS I LOCATIONS WEHICLES(ACORD 101,Addilional Remarks Schedule.maybe attached If mars space is required) ,City of Ashland,Oregon,along With Its elected officials,officers,and em.ployees,are included as additional insureds under General Liability,on a primary and non-contributory basis,when agreed In a written contract,subject to policy terms,conditions and exclusions. 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 East Main Street AUTHORIZED REPRESENTATIVE Ashland OR 97520 01988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016103) The ACORD name and logo are registered marks of ACORD www.salf.com SalWork. LifOre. Oregon. Oregon Workers' Compensation Certificate of Insurance Certificate holder: i CITY OF ASHLAN❑ 20 BAST MAIN STREET ASHLAND,OR 97520 The policy of insurance listed below has been issued to the insured named below for the policy period Indicated.The insurance afforded by this policy Is subject to all the terms,exclusions and conditions of such policy;this policy is subject to change or cancellation at any time. Insured Producer/contact Bell Hardware of Medford Inc SAIF Corporation 528 Main St SAIF Corporation Klamath Falls,Or 97601-6032 Issued 03/07/2026 Limits of liability Policy 344518 Bodily Injury by Accident $1,000,000 each accident Period 07/01/2025 to 07/0112026 Bodily Injury by Disease $1,000,000 each employee Body Injury by Disease $1,000,000 policy limit Description of operations/locationslspecial items Project:Replacement of doors at Briscoe School Waiver of subrogation effective 3/7126 for persons and/or organizations with whom the insured-employer is required by written contract to waive subrogation rights. Important This certificate Is issued as a matter of Information only and confers no rights to the certificate holder,This certificate does not amend,extend or alter the coverage afforded by the policies above.This certificate does not constitute a contract between the Issuing Insurer,authorized representative or producer and the certificate holder. Authorized representative i Chip Terhune President and CEO i t 3 400 High Street SE Salem,OR 97312 P:800.285.8525 Pollry_OLCA_CerlficateOtfnsarance F:503.584.9812 3 3 Form W"9 Request for Taxpayer Give form to the (Rev,.March 2024) Identification Number and Certification requester,Do not Department Revenue Senn€Ge �of the Treasury Go to www.irs.gov/F�onnW9 for instructions and the latest information, send to the IRS. Intternal Before you beg(rli For'guidance related to the)u"so'af Form W-9,see purpose,of Farm,below. 1 Name of entity/fndlvfdual.An entry is required.(Fur a sole proprietor or disregarded entity,enter the owner's name online t,and enter the businessldisregarded entity's name un fine 2.) BELL HARDWARE OF MEEDFORD„INC 2 Business name/disregarded entity name,it different from above. M 3a Check the appropriate box for federal tax classification of the entityfrndividua€whose name Is entered on fine 1.Check 4 Exemptions(nodes apply only to in only one of the following seven boxes. certain entities,not individuals: n see Instructions on page 3): ❑ Individual/sole proprietor ❑ C corporation ❑1 S corporation ❑ Partnership ❑ TrusVestate o n ❑ LLC.Enter the tax classification(C=C corporation,S-S corporation,P-Partnership) Exempt payee code(it any) a Note.,Check the"LLC"box above and,in the entry space,enter the appropriate code(C,S,or P)for the lax classification of the LLC,unless it is a disregarded entity.A disregarded entity should instead check the appropriate Exemption from Foreign Account Tax `o box for the tax classification of its owner. Compliance Act(FATCA)reporting 'C r ❑ Other(see instructions). code(if any) G tf 3b if on tine 3a you checked"Partnership"or"Trustleslate,'or checked"LLC"and entered"P"as its tax classification, (Applies to accounts mefntaPned n and you are providing this form to a partnership.trust,or estate in which you have an ownership interest,check outside the United States) fin this box if you have any foreign partners,owners.or beneficiaries.See instructions . ❑ 57 5 Address(number,street,and apt.or suite no).See instructions_ Requesters name and address(optionag 528 MAIN ST 6 City,state,and ZIP code KLAMATH FALLS,OREGON 97601 7 test account number(s)here(optional) Tax a tar Identification Number(r(N Enter your TIN in the appropriate box.The TIN provided must match the name given on line 1 to avold Seoul*mdtgnumber backup withholding.For individuals,this is generally your social security number(SSN).However,for a resident alien,sole proprietor,or disregarded entity,see the Instructions for Part 1,later.For other = — entities,it is your employer identification number(EIN).If you do not have a number,see Flow to get a or TIN,later. Lmployor ide[iliflcation rtumlaer Note.if the account is in more than one name,see the instructions for line 1.See also What Name and Number To Give the Requester for guidelines on whose number to enter. 4 3 - 0 7: 3 a' B 0 4 • Certification Under penalties of perjury.I certify that: 1.The number shown on this form Is my correct taxpayer identification number(or I am waiting for a number to be issued to me);and 2.1 am not subject to backup withholding because(a)I am exempt from backup withholding,or(b)I have not been notified by the internal Revenue Service(IRS)that I am subject to backup withholding as a result of a failure to report all interest or dividends,or(c)the IRS has notified me that I am no longer subject to backup withholding;and 3.1 am a U.S.citizen or other U.S.person(defined below);and 4.The FATCA code(s)entered on this form(if any)indicating that I am exempt from FATCA reporting is correct. Certification Instructions.You must cross out Rem 2 above if you have been notified by the IRS that you are currently subject to backup withholding because you have failed to report all Interest and dividends on your tax return.For real estate transactions,item 2 does not apply.For mortgage Interest paid, acquisition or abandonment of secured property,cancellation of debt,contributions to an individual retirement arrangement PPA),and,generally,payments other than interest and dividends,you are not required to sign the certification,but you must ptrfvidla.your correct TiN,See the instructions for Part 11,later. Sign Signature of .Here I iu s,person 1 :. Date [r • General Instructions New line 3b has been added to this form.A flow-through entity Is required to complete this line to indicate that it has direct or Indirect Section references are to the internal Revenue Code unless otherwise foreign partners,owners,or beneficiaries when It provides the Form W-9 noted. to another flow-through entity in which it has an ownership interest.This Future developments.For the latest information about developments change is intended to provide a flow-through entity with information related to Form W-9 and its instructions,such as legislation enacted regarding the status of Its indirect foreign partners,owners,or after they were published,go to www.1rs.gov/FormW3, beneficiaries,so that it can satisfy any applicable reporting requirements.For example,a partnership that has any Indirect foreign What's New partners may be required to complete Schedules K-2 and K-3.See the Partnership instructions for Schedules K-2 and K-3(Form 1065). Line 3a has been modified to clarify haw a disregarded entity completes this line.An LLC that is a disregarded entity should check the Purpose Of Form appropriate box for the tax classification of its owner.Otherwise,it An Individual or entity(Form W-9 requester)who is required to file an should check the"LLC"box and enter its appropriate tax classification. Infomtation retum with the IRS Is giving you this form because they Cat.No.10231x Form W-9(Rev.3-2024)