HomeMy WebLinkAboutInsurance Certificate: Potelco Inc
/"""""'\
ACORD" CERTIFICATE OF LIABILITY INSURANCE I DATE (MMfDDIYYYY)
~ 11n
PRODUCER John L. Wortham & Son, L.P. THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
P. O. Box 1388 ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
HOLDER. THIS CERTIFICATE DOES NOT AMEND. EXTEND OR
Houston, TX 77251-1388 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
713-526-3366
713-526-5587 INSURERS AFFORDING COVERAGE NAIC#
INSURED Potelco. Inc. INSURER A:. Old Renublic Insurance Comnanv 24147
14103 Stewart Rd. INSURER B: Ace Pronertv & Casualtv Insurance Co. 20699
Sumner WA 98390 INSURER c:
INSURER D:
I INSURER E:
COVERAGES
THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NQlWITHSTANDING
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 SUBJECT TO ALL THE TERMS. EXCLUSIONS AND CONDITIONS OF SUCH
POLlCIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
',N';;: -:.~~';:, ~D. POLlCY NUMBER POL.ICY EFFECTIVE ~<I~~! EXPIRATION LIMITS
A ~NERAL UABIUTY MWZY58873 8/1/2010 8/1/2011 EACH OCCURRENCE I 5000,000
I COMMERCIAL GENERAL LIABILITY PREMlseJ ?E~~~enC8\ I 5.000.000
- W CLAIMS MADE [Z] OCCUR MED ex? 'ArIv one person\ I!xcluded
- PERSONAl & ADV INJURY I 5,000.000
- GENERAL AGGREGATE I 5,000.000
-7l'L AGG~EnE ILlMIT APnSIPER: PRODUCTS - COMP/OP AGG I 5,000.000
I POLICY ~~,9; LOC
A ~TOMOBIL.E UAB1UTY MWTB21029 8/112010 8/112011
COMBINED SINGLE LIMIT I
~ ANY AUTO (Es8ccidenl) 5,000.000
-'- ALL OWNED AUTOS BODilY INJURY I
SCHEOULED AUTOS (Perpsrson)
-
i HIRED AUTOS BOOll Y INJURY
I
NON-OWNED AUTOS (Peracddent)
- PROPERTY DAMAGE I
(PlIraccident)
~RAGE LIABILITY AUTO ONLY. EA ACCIDENT I
ANY AUTO OTHER THAN EA ACe I
AUTO ONLY: AGG I
B 5ESS I UMBREL.LA LIABIUTY XOOG25908041 8/1/2010 8/1/2011 EACH OCCURRENCE I 5,000,000
OCCUR [Z] CLAIMS MADE AGGREGATE I 5,000,000
eM Retro Date 8/1/2002 I
;1 DEDUCTIBLE I
I RETENTION $ Der Dolicy I
A WORKERS COMPENSATION MWC 11672400 8/1/2010 8/1/2011 if I T"X~~T~N;.I IOJ,tl-
AND EMPLOYERS' LIABILITY YI"
ANY PROPRIETOR/PARTNER/EXECUTIVE [!!] E.L EACH ACCIDENT I 1 000 000
OFFICERlMEMBER EXCLUDED? N
(Mandatory In NH) E.L DISEASE - EA EMPLOYE I 1 000 000
~~~~I~S~~b~VIS1~NS below E.L DISEASE. POLlCY LIMIT I 1 000 000
OTHER
DESCRIPTION OF OPERATIONS' LOCATIONS /VEHICL.ES 'EXCL.USIONS ADDED BY ENDORSEMENT' 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 AddiUonallnsured When Required By Written Contract But Only As Respects Liability Arising Oul Of
Named Insured's Work For AddiUonallnsured.
CERTIFICATE HOLDER
CANCELLATION
SHOUL.D ANY OF THE ABOVE DESC RIBED POLICIES BE CANCEL.LED BEFORE THE EXPIRATION
The City Of Ashland, Oregon DATE THEREOF, THE ISSUING INSURER WlL.L. ENDEAVOR TO MAIL. ..1Q... DAYS WRITTEN
Attn: Kari Ann Olson NOTICE TO THE CERTIFICATE HOL.DER NAMED TO THE L.EFT, BUT FAlL.URE TO DO SO SHALL
90 N. Mountain Ave. IMPOSE NO OBLIGATION OR UABIL.ITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR
Ashland OR 97520 REPRESENTATIVES.
AUTHORIZED REPRESENTATIVE
John L Wortham & Son. L vrrlvvt.. !Jj,Jd:h4g - ~LI
ACORD 25 (2009/01)
@1988.2009ACORDCORPORATION. All rights rOBorvod.
CERT NO.' 7861792 CLIENT CODE: 10QUANTSER (HOU) Sandy Moore 7/18/2010 12:28 10 PH Page 1 of 2