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AUG-17-2007 08:21 FROM:ASHLAND INSURANCE 541 488 5851
TO: 4885320
P:l/3
JjC0110... CERTIFICATE OF LIABILITY INSURANCE I ~i~ Iri:/DPfY'm1
B 15 2007
F'~ODUC:EIt (541) 482-0831 FAX;: (541)488-5851 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
^shland Insurance Inc ONLY AND CONFERS NO RIGHTS UPOIll THE CERTIFICA T15
HOLDER. THIS CERTIFICATE DOES NOT AMENDe EXTEND OR
585 ^ Street Suite 1 ALTER THE COVERAGE AFFORDED BY THE POLlCI S eElOW.
P. O. Bo'!: S8a
Ashl.and OR 97,520 IIIlSURERS AFFORDING COVERAGE NAIC#
II\lBUREO INSUf!E:P. iI; 'l'ravel.oars
Durant-Newton EntQrpr~ses, Inc INSURF.R B:
DBA.: Brothers Restaurant 11'i6UReR c:
95 N. Hain at J!t~UR~R 0:
Ashland OR 971520 INSUFlER E'
THS POLICIES OF INSURANCE l.ISiED 6EI,Ow HAVS BEEN ISSU~O TO THE INSURED NAMED ABOVl: FOR THE POL.IC"( PERIOD INOlCATED. NOTV'lllTHSTANDING ANy
REQUIREMENT, TERM OR CONDITION OF "Ny CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WliICH THIS CSRTIFICAT'E MAY BE ISSUEo OR MAY PERTA.IN,
THE INSURANCS AFFORDF,O BY THE POL.IICIEiS DESCRIBED HEREIN IS SUBJECT TO Au THE TERMS, F-XCLUS10NS AND CONDITIONS OF SUCH POLICIES,
' ,",AVIO I RV PAl.......' A Il.~
I~~ ~'?:~ 'IYF'E OF INSUFlANcli POL,CY NUMIJEIt "~~,:~~g~,1!! ~~~,r:~~t~~N IJI.,ITS
~NI3I\AL L.lJ\IiIIUTY I=At:H A 1,000,000
.15. jMMmtCIAI. OENEIML. L.IAElILlTT p'~~l,~~IfJ?,,~"IIITED & 300,000
^ X - CU\IM!! MADO GJ OCCUR 690-5670L020 g/4/2007 9/4/2008 Ml"c [;xP (IInv one ""'oanl , 5,000
. An" 0.,,, .n_ . 1,000,000
-
~ Liquor Liaib11ty Gf.~EflIIL AG"~I"GAT" . 2,000,000
nL AGGFlne LIMIT AnES pe~, . "......"....... ."" , 2.000,000
POLICY P,~,9.,: Loe Li="'r: Ueb11illY $1.000 000
~TOMOBILE LIABILI1Y COMBINEO SINOLE LIMIT
(F-A Accldl!ll\l) ,
- ANY AUTO
- ALL OWNeD AUTOS RODILT INJURY
(Porl''''I".,,") ,
r-- SCHEDULEP AUTOS
- HIREr:! AUTOS BOPILY INJURY ,
(Pill' .""'<lRnU
- NON.O\l\oNED AUTOS
- - pnOPF.R1Y DAMAGF. &
[PM 8cc1dDnll
=fAillE LIABILITY ..ll..1,l.I.O ONLY" eA ACCIDENT ,
AN'" AUTO OTHI2R THAN I=A A(",(",
AUTO ONLY; AGG
EXOI!!S8IUMBRl3LlA LIABI\..I1Y ., Ie
UOCCUR 0 Ct.AIMS MADE; AGGROGATF. I,
~ D"OUCTIBLIl ,
e
, ~
WOJIIKERB COMPEN'4T1oN A".D we STAH,!, I IOJr-
I!MPLO'l'liiRS' L1AElILI1Y o L . I;AI"!H ACCID!;NT I A
ANY i>ROPRIETORlPARTNfRlEXeOUTIVE
OFTICF.RJMEMElER EXCLUOF-P? F.,.kOI9EASE. Ji',A EMPLOY~ .
~~~~t~~""I1b8 undnr
"AOV EJ. OISI;I\"" -1'>01 ICY LIMIT I,
OTHEFl
DESCRIPTION OF OPEItAnON9ILOCATlONBNEHICLIiSI'IlXCI-USION9 AD"IOD BY ENDQR81iIllBNT/IlF'F.CIAI- PJIIOVJ$lON9
The C1~Y o~ Ashland, it. offie~re ~nd emp1oY4ee ar~ named _. addie1on~ 1n.urQds
CEFlTIFICATE HOLDER
(541)488-5320
City of' Ashland
20 E. Main St.
^shland, OR 97520
CANCELLATION
SHOUI-" ANY 0" TH& ABOVE OliSCJIIIBEIl F'OLIOlss BE CANC:EL",ED 8&1'0"9 111E
EllPIRATlON DATF. THI!I\I!OF, THIi IS.llUI"'l) INSUI\EIl WILL I!NOE4VOf' TO MAIL
~ DAn WRITTE" I\IOTIC:I! TO THIi CIiIll""'C~T1i HOLDe" HAMiD TO THF. LIiFr, BUT
flAIJ,.UFlE TO DO SO SHALL IMF'OsE NO OI!lI-,OATlOIt OR LIASI...I'IY 0.. ^"'I' KIND UPO" THE
NeUReR ITS ACF.NTS 0 PRE8IiNTA"~B.
AUTHO"'ZEll ~IiPItE$ AT ~
ICORD 25(2001/08)
I.IS025 (010D).0Il.
ll:l ACORD CORPOFlATION 1988
PBCI<l1 a'~
RUG-17-2007 08:21 FROM:RSHLRND INSURRNCE 541 488 5851
TO: 4885320
P:2/3
IMPORTANT
If the certificate holder Is: an ADDITIONAL INSURED, the policy(les) must be endorsed. A stat.ement on this
certificate does not confer rights to tho certIficate holder In lieu of such endorsement(s).
If SUBROGATION IS WAIIVED, 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).
DISCLAIMER
The Certificate of Insurance on the reverse side of this form does nol constitute a contract between the issuing
insurer(s), authorized reprlesentative or producer, and the certificate holder, nor does It affirmatively or negatively
amend, extend or alter the coverage afforded by the policies listed thereon.
ACORD 25 (2001/08)
l/IlS02! (1l10B).OBa
Page 2 012
RUG-17 - 2007 08: 21 FROM : R~3HLRND I NSURRNCE 541 488 5851
TD:4885320
P:3/3
POliCY NUMBER:
6BO,..S6lZ0L020
COMMERCIAL GENERAL LIABILITY
CG 20 11 01 86 Modified
THIS ENDORSEME:NT CHANGES THE POLICY, PLEASE READ IT CAREFULLY.
ADDITIONAL INSURED.. MANAGERS OR LESSORS
OF PREMISES
This endorsement modifies Insurance provided under the following:
COMMERCIAL GENERAL LIABILITY COVERAGE PART.
SCHEDULE
1. Designation of Premises (Part Leased to YOU):
2. Name of Person or Organization (Additional Insured):
Cit:y of Ashland
20 E Ma,in St
Ashla,nd OR 97520
3. Additional Premium:
(If no entry appears above. thl~ information required to complete this endorsement will be shown In the
Declarations as applicable to this endorsement)
WHO IS AN INSURED (SectlCln II) is amended to include as an insured the person or organization shown In the
Schedule but only to the extent the person or organization is held liable as a result of the ownership, maintenance
or use of that part of the premises leased to you and shown In the Schedule and subject to the following additional
exclusions:
This im~urance does not apply to:
1. Any "occurrenoe" which takes place after you cease to be a tenant in that premIses.
2. Structural alterations. new construction or demolition operations performed by or on behalf of the person or
organization shown in the Schedule.
CG 20 11 01 96 Modified Page 1 of 1
Includes copyrighted material of Il'1Surance Services Office, Inc., with its permission.