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ACORD,. CERTIFICATE OF LIABILITY INSURANCE I DATE (1II111Dtln'YYY)
5/20/2005
PftllDUCER (541)772-1111 FAll (541) 772-3785 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
S.gu~1ty In.Q~ange Ageaoy ONLY AND CONFERS NO RIGHTS UPON THE CERlFICATE
HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
707 HuEphy Roacl ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
Meclforcl OR 97504 INSURERS AFFORD"O COVERAGE NAIC t#
INSURED INSURER It .Am.r1oan Sut.. In.Q~ilnge U704
BALLE'!' ROGUE INSURER B:
PO BOX 785 INSURER C:
INSURER D:
MEDJ'ORD OR 97501 INSURER E:
COVERAGES
THE POUClES 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 CON'TRACT 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 CCHlI'TlONS OF SUCH POLICIES.
AOOREaATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
- DD'L ~:i~~ ~fl(~~N
TYPE Of' IN8lJRANCE POLICY NUMBER LIMITS
~ERAL LIA!lILITY EACH OCCURRENCE $ 1,000,000
..!. TRClAL GENERAl UABlUTY ~~~~~~9E:~~""'1 s 200,000
A I-- CL.AJ1I1S MADE ~ OCCUR OlCC20l65780 5/18/2006 5/18/2007 Mal EXP (Anv one oersonl S 10,000
PERSONAL & MJV INJURY S 1,000,000
GENERAL AGGREGATE $ 1,000,000
Iii'L AGGRnE LIMIT "'FiS PER: PRODUCTS - COMPIOP ItGG S 1,000,000
X POLICY ~ LOC
~ClMOILE LIABILITY COM81Nal SINGLE UMIT S
(Ea accident)
I-- ANY AUTO
I-- ALL OW\lal AUTOS BODILY INJURY
(Per """,on) $
~ SCHECUUEO AUTOS
~ HIRED AUTOS BODILY INJURY S
NON.OWNED AUTOS (per accIOenQ
I--
PROPERTY DAMAG E S
(Per lICCidenQ
ClMAGI! LIA!lILITY AUTO ONLY. EA ACCIDENT S
R I<NY AUTO OTHER THI<N EA ACC 5
AUTO ONLY: ItGG S
[jES&IUMBREULA UABlUTY EACH OCCURRENCE $
OCCUR 0 CL.AJMS MADE AGGREGATE S
S
R DEDUCTIBLE S
RETENTION $ S
WORKER. CCMPENIIA TION AND I T~.nr.lt!fs I IUE~
IMPLOYDS' LIAalLITY
ANY PROPRIETOR/PARTNERlEXECUTIVE EL EACH ACeI DENT S
OFFICE_EMBER EXCLUDED? EL DISEASE. EA EMPLOYEE S
W yes. dnaIle under
SPECIAL PROVlSIONS_ EL. DISEASE. POUCY LIMIT S
OT_
DESCRIPTION OF OPERATIONSIlOCATIONSlVEHICLESlEXCLUSlONSADDED BY ENDORSEMENT/SPECIAL PROVISIONS
The City o~ Ashland, its ot~icers, and .mployees are hereby named as additional insured with respects to General
:r.1a.t>il1ty InSUrance when requ.1red by written agreement per Blanket Additional Insured endoors_nt. This fOl:lll is
subjeet to polic:y terms, eond1tions and exclusions
CERTIFICATE HOLDER
CANCELLATION
488-5311 SHOULD ANY Of' THE AIlOYE D~IBED POLICIES BE CANCELLED BEfORE THE
Ci 1;y of uhland EXPIRATION DATE THEREOF, THE ISSUING INSURER WIUL ENDEAVOR TO MAlL
Bryn Ncrriaon 10 DAYS WRITTEN NOncE TO THE CERTIFICATE HOLDER NAMED TO TIE LEFT, BUT
20 East MAin street -
FAILURE TO DO so lIHALL IMPOllE NO OBUGATION OR LIABILITY OF ANY KIND UPON THE
bhlancl , OR 97520
"SURER ITS AOENTS Oft REPIlESENTATIYE$.
AUTHORIZED REPRESENTA TIYE ~~
Rim Edwards/RIMED
ACORD 21 (2001108)
IN6021 (DHJIl)_1l!l AM6
VMP Mongoge Solut..,s, Inc. (8OO)327.064C
c> ACORD CORPORA l10N 1888
Poge 1 d2
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