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ACORD" CERTIFICATE OF LIABILITY INSURANCE I DATE (MMlDOfYYYYl
OP ID DR
~ 06/22/10
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
BELOW, THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED
REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER.
IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, 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).
PRODUCER NAME:
Insurance Marketplace, Inc. I fl1gN~o, Ext\: IIAIC,NO)'
1998 Skypark Dr suite 100 I AOMDRESS:
Medford OR 97504 ~SI[ID#: SABEL-1
Phone:541-779-0177 Fax: FAX 772-8235 INSURER(S) AFFORDING COVERAGE NAIC#
INSURED INSURER A ; Austin Mutual Ins 13412
Sabel Painting CO INSURER B :
Jim Sabel
3181 Old sta~e Rd INSURER C :
central Po in OR 97502 INSURER 0 :
INSURER E :
INSURER F :
...----,
COVERAGES
CERTIFICATE NUMBER:
REVISION NUMBER:
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED. NOTWITHSTANDING Am 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 SUBJECT TO ALL THE TERMS,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. UMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
,ILtR TYPE OF INSURANCE ADD := IM1.iM\i;m" (~Wii5lMY> LIMITS
INSR POLICY NUMBER
GENERAL LIABILITY EACH OCCURRENCE $
e-
COMMERCIAL GENERAL LIABILITY ~REM:S~S (~occurrence) $
I CLAIMS-MADE 0 OCCUR MED EXP (Anyone person) $
e- PERSONAL & ADV INJURY $
e- o GENERAL AGGREGATE $
n'L AGG~EnE LIMIT APnS PER: PRODUCTS - COMP/OP AGG $
POLICY j~8T LOC $
AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ 1000000
~ (Eaaccident)
A - ANY AUTO 01 BA 1900827 05 06/13/10 06/13/11 BODILY INJURY (Per person)
$
- ALL OWNED AUTOS BODILY INJURY (Per accident) $
~ SCHEDULED AUTOS PROPERTY DAMAGE
~ HIRED AUTOS (Per accident) $
~ NON-OWNED AUTOS $
. $
UMBRELLA LlAB H OCCUR EACH OCCURRENCE $
e-
EXCESS L1AB CLAIMS-MADE AGGREGATE $
e- DEDUCTIBLE $
RETENTION $ $
WORKERS COMPENSATION IT~~v"I,tWs I IOJ~o
AND EMPLOYERS' LIABILITY VIN
ANY PROPRIETORlPARTNERlEXECUTIVO " E.L. EACH ACCIDENT $
OFFICER/MEMBER EXCLUDED?
(Mandatory in NH) E.L. DISEASE - EA EMPLOYEE $
If~es,desCribeunder
D SCRIPTION OF OPERATIONS below E.L. DISEASE - POLlCY LIMIT $
DESCRIPTION OF OPERATIONS f LOCATIONS I VEHICLES (Attach ACORD 101, Additlonal Remarks Schedule, if more space is required)
1990 Chevrolet C2500 PICKUP 1GCGC24KXLE262449
BLANK-1 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE OEUVEREO IN
City of Ashland all officers ACCORDANCE WITH THE POLICY PROVISIONS.
and Employees
Kari Olson AUTHORIZED REPRESENTATIVE
20 E Main St
Ashland OR 97520 Kevin Cope
,
CERTIFICATE HOLDER
CANCELLATION
ACORD 25 (2009/09)
@1988-2009 ACORD CORPORATION. All rights reserved.
The ACORD name,and logo are registered marks of ACORD