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Home My WebLink AboutInsurance Certificate: Potelco Inc CITY RECORDER ~ ,ACORD" CERTIFICATE OF LIABILITY INSURANCE I DATE (MMJODNYYY) .~ 7/2Q/2nnQ PRODUCER John L. Wortham & Son, L.P. THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE 2727 Allen Parkway HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR Houston, TX 77019 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. 713-526-3366 INSURERS AFFORDING COVERAGE NAIC# www.worthaminsurance.com INSURED Potelco, Inc. INSURER A: Old Reoublic Insurance Comoanv 24147 14103 E~th Street East INSURER B: Ace Prooertv & Casualtv Insurance Co. 20699 Sumner A 98390 INSURER c: INSURER 0: , INSURER E: COVERAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOlWlTHSTANOING 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 SUBJECTTO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR DD' POLICY NUMBER ~P'}Jsr..~f~~~, I ~~~!fY EXPIRATION LIMITS A ~NERAL LIABILITY EACH OCCURRENCE $ 5 000 000 .x:.. pMERCIAI. GENERAL L1ARILlTY MWZY58430 8/1/2009 8/1/2010 DAMA~I:.! 9_ ~I:NTI:D , 5000.000 PREM~S::S 'Ea occurrence' _ CLAIMS MADE [2] OCCUR MED EXP (Anyone person) , excluded PERSONAL & ADV INJURY $ 5 000 000 GENERAL AGGREGATE $ 5 000 000 7]'L AGG~EnE ILlMIT APnSI PER: PRODUCTS - COMP/OP AGG $ 5 000 000 I POLICY ~li'~T LOC A ~TOMOBILE LIABILITY COMBINED SINGLE LIMIT MWTB20698 8/112009 8/1/2010 $ ANY AUTO (Eaaccidenl) 5 000 000 ~ ALL OWNED AUTOS BODILY INJURY $ SCHEDULED AUTOS {Per person) ~ HIRED AUTOS BODILY INJURY $ .L NON-OWNED AUTOS (Peraccidenl) - PROPERTY DAMAGE $ (Per accident) ~RAGE LIABILITY AUTO ONLY - EA ACCIDENT $ ANY AUTO OTHER THAN EAACC $ AUTO ONLY: AGG $ B 5ESS / UMBRELLA LIABILITY XOOG24898970 8/1/2009 8/1/2010 EACH OCCURRENCE $ 5 000 000 OCCUR [Z] CLAIMS MADE AGGREGATE $ 5 000 000 $ :;:j DEDUCTIBLE CM Retro Date 8/1/2002 , I RETENTION $ See oaae 3 $ A WORKERS COMPENSATION MWC11619200 8/1/2009 8/1/2010 .; I T';(g~T~J,~~ I IOJ~- AND EMPLOYERS' LIABILITY YIN ANY PROPRIETOR/PARTNERlEXECUTIVE ~ E.L. EACH ACCIDENT $ 5 000 000 OFFICER/MEMBER EXCLUDED? N (MilndatoryIn NH) ~:L. DISEASE.~ EMPLOYE $ 5"QQQJL~ ~~~~1~tS~~~01~1ctNS below E.L. DISEASE. POLICY LIMIT $ 5 000 000 OTHER DESCRIPTION OF OPERATIONS I LOCATIONS IVEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS Re: All Operations General Liability And Auto Liability Policies Include The City Of Ashland, Oregon, And Its Elected Officials, Officers And Employees As An Additional Insured When Required By Written Contract But Only As Respects Liability Arising Out Of Named Insured's Work For Additional Insured. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION The City Of Ashland, Oregon DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL ..lQ.... DAYS WRITTEN Attn: Kari Ann Olson NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL 90 N. Mountain Ave. IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR Ashland OR 97520 REPRESENTATIVES. AUTHORIZED REPRESENTATIVE John L. Wortham & Son, loP. -Qa/vxJt.. !J}/J/tih4rJ ~ JAJi ACORD 25 (2009101) @198B-2009ACORD CORPORATION. All rights reserved. CERT NO.. $4$94.60 CLIENT CODE: lOQUANTSER (HOUl Sandy Moore 7/29/2009 2,28:44 PM Page 1 of 3 IMPORTANT If the certificate holder Is an ADDITIONAL INSURED, the pollcy(les) must be endorsed. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). If SUBROGATION IS WAIVED, subject to the terms and conditions of the polley, 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 not constitute a contract .between the issuing Insurer(s), authorized representative or producer, and the certificate holder, nor does it affirmatively or negatively amend, extend, or alter the coverage afforded by the policies listed thoreon. CANCELLATION NOTICE The CANCELLATION NOTICE on the CERTIFICATE OF INSURANCE Is amended to Include the following wording: The Insurance Companies may cancel the described pollcy(ies) by mailing or delivering ten (10) days written notice of cancellation to the Named Insured for: (1) Non Payment of premium of (2) any other circumstance permitted by state law or policy conditions. ADDITIONAL INSURED DISCLAIMER Coverage for Additional Insureds can vary significantly from policy to polley and thus Additional Insured status does not guarantee protection for all losses. Coverage Is subject to actual polley terms and conditions. CERT NO.: 5459460 CLIENT CODE: lOQUANTSER (HOU) Sandy Moore 7/29/2009"2:28:44 PM Page 2 of ) .[CERTIFICATE - ATTACHMENT '~ ,_~' ",~~' .: :\,~:;' t _..,.:t< ,. ..;-:,..] Named Insured: Issue Dllle: 7/29/2009 Potelco, Inc. 14103 Eighth Street East Sumner WA 98390 Excess Liability: SIR: $5,000,000 Each Occurrence Without Aggregate CERT NO.. 5459460 CLIENT CODE: lOQUANTSER (HOU) Sandy Moore 7/29/2009 2:28:44 PM Page 3 of 3 John L. Wortham & Son, L.P. 2727 Allen Parkway Houston, TX 77019 MAIL DOCUMENT Certificate of Insurance Delivery by ecertsonline ™ The City Of Ashland, Oregon Altn: Kari Ann Olson 90 N. Mountain Ave. ASHLAND OR 97520 P~S~~d~;:j (HOU) Sandy Moore p;}h,;ne:!713-526-3366 l~~r~..i.b'" -."'J Certificate of Liability: Quanta Services, Inc. ~j~ k",Dat~:17/29/2009 I No.'of Pag~ 4 [';'. URL:! www.worthaminsurance.com THIS MESSAGE IS INTENDED FOR 1l1E USE OF THE INDIVIDUAL OR ENTITY TO WHICH IT IS AOORESSED AND MAY CONTAIN INFORMATION THAT IS PRMLEGEO, CONFIDENTIAL AND EXEMPT FROM DISCLOSURE UNDER APPlICABLE LAW. IF THE READER OF THE MESSAGE IS NOT THE INTENDED RECIPIENT, OR THE EMPLOYEE ORAGENT RESPONSIBLE FOR DELIVERING THE MESSAGE TO THE INTENDED RECIPIENT. YOU ARE HEREBY NOTIFIED THAT AtN DISSEMINATION, DISTRIBUTION OR COPYING OF THIS COMMUNICATION IS STRICTLY PROHIBITED. IF YOU HAVE RECENED THIS COMMUNICATION IN ERROR, PlEASE NOTIFY US IMMEDIATE" Y BY TelEPHONE, AND RETURN THE ORIGINAl. MESSAGE TO US AT THE AOCNE ADDRESS VIA REGUlAR POSTAL SERVICE. Ii) 2002 Certificate oflnsurance Delivered by ecertsonline™ Insurance Visions, Inc. All rights reserved.