HomeMy WebLinkAboutInsurance Certificate: Mediation Works
ApI' 03 09 04: 1 Op
JON SNOWDEN. STATE FARM
5414824957
p.2
Policy Number
97-BG-9222-6
DECLARATIONS PAGE
COVERAGE SUMMARY
MAR 10 2009
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STATE FARM FIRE AND CASUALTY COMPANY
PO BOX 5000, DUPONT WA 98327-5000
A STOCK COMPANY WITH HOME OFFICES IN BLOOMINGTON, ILLINOIS
Named Insured and Mailing Address
15-9A 13-F490 I
MEDIATION WORKS. A COMMUNITY
DISPUTE RESOLUTION CENTER
33 N CENTRAL AVE STE 219
MEDFORD OR 97501-5939
COy A - Inflation Coverage Index: N/A
BUSINESS POLICY - SPECIAL FORM 3 COy B - Consumer Pricelndex: 220MO
AUTOMATIC RENEWAL - If the POLICY PERIOD is shown as 12 MONTHS, this policy will be renewed automatically
subject to the premiums, rules and forms in effect for each succeeding policy period. If this policy is terminated, we will
give you and the Mortgagee/Lienholder written no1ice in compliance witli the policy provisions or as required by law.
Policy Period: 12 Months The ~Olicy peri.?d begins and ends at 12~01 am standard time at the
Effective Date: MAR 31 2009 premises locatron.
Expiration Date: MAR 31 2010
Named Insured: Corporation
Location of Covered Premises:
33 N CENTRAL AVE STE 219
MEDFORD OR 97501-5939
Coverages & Property
Section I
A Buildings
B Business Personal Property
C Loss of Income - 12 Months
Lim its of Insurance
Excluded
$ 28 600
$ Actual [ass
Section II
L Business Liability
M Medical Payments
Products-Completed Operations
(pea) Aggrega1e
General Aggregate (Other
Than PCO)
$
$
Deductibles - Section r
1,000,000
5,000
Excluded
2,OOO~OOO
$ 500 Basic
$
Forms, Options, and Endorsements
Special Form 3
Policy Endorsemen1- Business
Amendatory Collapse
Fungus (I ncluding Mold) Excl
Building Coverage tor Tenan1s
Policy Endorsemem- Business
Policy Endorsement
FP-6103
FE-6851
FE-6573.1
FE-6566
FE-6859
FE-6610
FE-6656
In case of lo~s under this policYI the deductible will be
appUed to each occurrence and will be deducted from the
amount of the loss. Other deductibles may apply - refer to
policy.
POlicy Premium $ 300.00
Minimum Premium
Discounts Applied:
Claim Record
Prepared
v1AR 1 0 2009
=-P-8030.2C
) 6/1 993
four policy consists of this page, any endorsements
lnd the policy form. PLEASE KEEP THESE TOGETHER.
Continued on Reverse Side of Page
OTHER LIMITS AND EXCLUSlONS MAY APPLY- REFERT YOUR POLICY
Count rsigned 3 17
By
JON SNOWDEN
{541) 482-2461
CGET
Agent
(o1f2172b)
'r I
Apr 03 09 04: 1 Op
JON SNOWDEN STATE FARM
5414824957
p.3
SECTION II ADDlTIONAL INSURED ENDORSEMENT
FE-6609
Page 1 of 1
Policy No.: 97-BG-9222-6
Named Insured:
MEDIATION WORKS, A COMMUNllY
DISPUTE RESOLUTION CENTE R
33 N CENTRAL AVE STE 219
MEDFORD OR 97501-5939
.$1"11 '''1''''
A
'''SVUHCf.
Additional Insured (include address):
CITY OF ASHLAND ITS OFFICERS,
EMPLOYEES &AGENTS
20 E MAIN ST
ASHLAND OR 97520-1850
- ...----.-. ------...------- -,...-.--.. -------....-
WHO IS AN INSURED, under SECTION II DESIGNATION OF INSURED, is amended to include as an insured the
Additional Insured shown above, but only to the extent that liability is imposed on that Additional Insured solely because
of your work performed for that Addiiionallnsured shown above.
Any insurance provided to the Additional Insured shall only apply with respect to a claim made or suit brought for
damages for which you are provided coverage.
The Primary Insurance coverage below applies only when there is an "X" in 1he box.
o Primary fnsurance. The insurance provided to the Additional Insured shown above shall be primary insurance.
Any insurance carried by the Additional Insured shall be noncontributory with respect to coverage provided to
you.
All other provisions of the policy apply.
FE-6609
'1 I