HomeMy WebLinkAboutInsurance Certificate: Key Line Construction
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CITY RECORDER
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ACORD~ CERTIFICATE OF LIABILITY INSURANCE DATE (MMIDDIYYYY)
11/13/2009
PRODUCER (541) 772-1111 FAX: (541) 772-3785 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
Beecher Carlson Agency LLC ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
Insurance HOLOER. THIS CERTIFICATE DOES NOT AMEND. EXTEND OR
707 Murphy Rd ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
Medford OR 97504 INSURERS AFFORDING COVERAGE NAIC#
INSURED !NSURERA: Financial Pacific Ins Co
Key Line Construction, Inc. INSURER B:
6687 Tole Road INSURER c:
INSURER D:
Central Point OR 97502 INSURER E:
THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOlWfTH$TANDING ANY
REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,
:~E ~~~U~~CE T~F!.?~DED B-:, ~~~ ~9;.1?~~Snl~;~C~~ED ~~~EI~c:IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.
A GR AT 1M IT H W MAY AV N ED ED B PAID LAIM
INSR ADO'L. P~A~~~~~~gg~\E Pg~~,~~tWt~N L.IMITS
TYPE OF INSURANCE POLICY NUMBER
~NERAL. LIABILITY I "ACH nccURo'NcE $ 1,000,000
X COMMERCIAL GENERAL. LIABILITY I ~~~~I~}?ERENTE~ n'-' $ 100,000
A I CLAIMS MADE [!] D~CUR 173496E 11/22/2009 11/22/2010 'MEDEXP'An one erson' $ 5,000
P"'RC'......NA' . AnV IN_IlIRy $ 1,000,000
GENERAL AGGREGATE $ 2,000,000
~'L AGG~EnE LIMIT APlES PER: por'lnI'f"TS _ f".....MPIOP "'''G $ 2,000,000
X POLICY ~~-9-i LOC
~TOMOBIL.E LlABIL.ITY COMBINED SINGLE LIMIT $ 1,000,000
ANY AUTO (Ea accident)
-
A - ALL OWNED AUTOS 173496E 11/22/2009 11/22/2010 BODILY INJURY
(Per person) $
~ SCHEDULED AUTOS
~ HIRED AUTOS BODILY INJURY
~ (Peraccidenl) $
NON-oWNEO AUTOS
PROPERTY DAMAGE $
(per accident)
==fAGE LIABILITY AUTO ONLY - EA ACCIDENT $
ANY AUTO OTHER THAN "AACC $
AUTO ONLY: AGG $
~ESSIUMBRElLA LIABILITY $ 5,000,000
OCCUR D CLAIMS MADE AGGREGATE $ 5,000,000
~ ~EDUCTIBlE $
A 922533E 11/22/2009 11/22/2010 $
X RETENTION ~ 0 $
WORKERS COMPENSATION AND i WC 3TATU- IOJ.t.I"
EMPL.OYERS' LIABILITY
ANY PROPRIETOR/PARTNER/EXECUTIVE EL EACH ACCIDENT $
OFFICER/MEMBER EXCLUDED? EL DISEASE - EA EMPLOYEE $
If yes, describe under
SPECIAL PROVISIONS below E.L. DISEASE - POLICY LIMIT $
A OTHER Leased or Rented 173496E 11/22/2009 11/22/2010 Limit $100,000
Equipment Deductible $1,000
DESCRIPTION OF OPERATIONS/L.OCATIONSNEHICLESIEXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS
Re: Quincy Street primary Fault Repair project #000085
The City of Ashland, its officers, and employees shall be named as Additional Insured as respects to General
Liability. 10 Day Notice of Cancellation for Non-Payment of Premium. Subject to policy Limits. Terms Conditions and
Exclusions.
CERTIFICATE HOLDER
CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCEL.LED BEFORE THE
City of Ashland EXPIRATION DATE THEREOF, THE ISSUING INSURER WlLL ENDEAVOR TO MAil
90 N Mountain Avenue 30 DAYS WRITTEN NonCE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT
Ashland, OR 97520 -
FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION OR LIABIL.ITY OF ANY KIND UPON THE
INSURER, ITS AGENTS OR REPRESENTATIVES.
AUTHORIZED REPRESENTATIVE ~4
Darrin Godfrey!KRISMA ~
ACORD 25 (2001/08)
INS025 (0108),08a
@ACORD CORPORATION 1988
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. )'POLlCY NUMBER 173496E
COMMERCIAL GENERAL LlABLlL TY
CG 20 10 Blanket Additional Insured 01 08R
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
ADDITIONAL INSURED - OWNERS, LESSEES OR
CONTRACTORS
(WITH LIMITED COMPLETED OPERATIONS COVERAGE)
This endorsement modifies insurance provided under the following.
COMMERCIAL GENERAL LIABILITY COVERAGE PART
BUSINESSOWNERS COVERAGE FORM
SCHEDULE
NAME OF PERSON OR ORGANIZATION.
Any person or organization to whom or to which
the named insured is obligated by a virtue of a
written contract to provide insurance that is
afforded by this policy. Where required by
contract the officers, officials, employees,
directors, subsidiaries, partners, successors,
parents, divisions, architects, surveyors and
engineers are included as additional insureds. All
other entities, including but not limited to agents,
volunteers, servants, members and partnerships
are included as additional insureds, if required by
contract, only when acting within the course and
scope of their duties controlled and supervised by
the primary (first) additional insured. If an Owner
Controlled Insurance Program is involved, the
coverage applies to off-site only. If the purpose
of this endorsement is for bid purposes only, then
no coverage applies.
WHO IS AN INSURED.(Section II)
This section is amended to include as an insured
the person or organization shown on the
Certificate of Insurance, but only to the extent
that the person or organization is held liable for
your acts or omissions arising out of and in the
course of "your work" for that person or
organization by or for you. The 'products.
completed operations hazard" portion of the
policy coverage does not apply to any work
involving or related to properties intended for
residential or habitational occupancy (other than
apartments).
WAIVER OF SUBROGATION.
We waive any right of recovery that we may have
against the person or organization shown in the
Schedule above because of payments we make
for injury.
LOCATION OF JOB.
The job location must be within the State of
domicile of the named insured, or within any
contiguous State thereto.
DESCRIPTION OF WORK:
The type of work performed must be that as
described under classifications in the CGL
Coveraoe Part Declarations.
CONDUIT CONSTR FOR CABLES/WIRES
PRIMARY CLAUSE:
When this endorsement applies and when
required by written contract, such insurance as
is afforded by the general liability policy is
primary insurance and other insurance shall be
excess and shall not contribute to the insurance
afforded by this endorsement.
EXCLUSION.
The insurance provided to the additional insured
does not apply to "bodily injury", "property
damage" or "personal and advertising injury"
arising out of an architect's, engineer's or
surveyor's rendering or failure to render any
professional services, including:
1. "The preparing, approving, or failing to
prepare or approve, maps, designs, shop
drawings, opinions, reports, surveys, field
orders, change orders, or drawings and
specifications; and
2. Supervisory, inspection, architectural or
engineering. activities.
Endorsement
EFFECTIVE DATE.
11/22/2009
Endorsement
EXPIRATION DATE.
11/22/2010
CG 20 10 Blanket Additional Insured 01 08R
Includes copyrighted material of Insurance Services Office, Inc., with its permission
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