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ACORD" CERTIFICATE OF LIABILITY INSURANCE I DATE (MMIDDIVYVY)
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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 aElWEEN THE ISSUING INSURER(S), AUTHORIZED
REPRESENTATIVE OR PRODUCER, ANO THE CERTIFICATE HOLDER.
IMPORTANT: If the certificate holder Is an ADDITIONAL INSURED, the pollcy(les) must be endorsed. If SUBROGATION IS WAIVED, subject to
the tenns and condWana 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 endorsemenU8).
PRODUCER 806-880-4280 CONTACT
NAME:
Riviera Insurance Service, LLC 806-880-4269 I rt,gN,fo Extl: Ir~Nol:
3710 State Sl Suite B e-MAIL
Santa Barbara, CA 93106 ADDRESS:
Christopher Hill ~~~: 10 #: CMCRE-1
IN5URER(S) AFFORDING COVERAGE HAle.
INSURED CMC Rescue INSURER', Liberty Surplus Insurance Corp
Attn: Tamle Kennedy INSURER B : Allied Insurance
P.O. Box 8870
Santa Barbara, CA 93180-6870 INSURER C :
INSURER D :
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 ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT VV1TH 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. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
INSR TYPE OF INSURANCE .~MB~ I.~MB~' LIMITS
LlR POLICY NUMBER
GENERAL UABILlTY EACH OCCURRENCE $ 1,000,001
-
A ~ 3MMERClAL GENERAL LIABILITY DGLLA2078232 0B/Ol110 08ID1/11 PREMISES Ea occurrencel $ 60,001
_ CLAIMS-MADE D OCCUR MED EXP (Any one pe~on) $ 5,001
PERSONAL & ADV INJURY $ 1,000,001
GENERAL AGGREGATE $ 2,000,001
~'~AGGREnEILlMIT APnS [PER: PRODUCTS - CQMPIOP AGG $ 2,000,000
POLICY ~~RT lOC $
AUTOMOBILE UABIUTY COMBINED SINGLE LIMIT $ 1,000,000
X (Eaaccident)
B ANY AUTO A.CP7804801910 0B/Ol110 08ID1111
-"- BODilY INJURY (Per person) $
- All OINNED AUTOS BODilY INJURY (Per accident) $
- SCHEDULED AUTOS PROPERTY DAMAGE
HIRED AUTOS (Per accident) $
-
NON-QINNED AUTOS $
-
$
UMBRELLA UAB H ~CCUR EACH OCCURRENCE $
- EXCESS L1AB
CLAIMS-MADE AGGREGATE $
- DEDUCTIBLE $
RETENTION $ $
WORKERS COMPENSATION IT~~IfJ#~ I PJ~-
AND EMPLOYERS' LIABILITY V,N
ANY PROPRIETOR/PARTNER/EXECUTIVE D E,l_ EACH ACCIDENT $
OFFICERIMEMBER EXCLUDED? NI. E.l. DISEASE - EA EMPLOYEE S
lMandltory In NHI
If yes, desaibeuncklr
DESCRIPTION OF OPERATIONS below E.L DISEASE. POLICY LIMIT $
DESCRIPTION OF OPERATIONS f LOCATIONS I VEHICLES (Attach ACORD 101, Additional Remaltts ScheduSe, If more space is ~ulred)
Proof of Insurance
CERTIFICATE HOLDER
CANCELLATION
ASH-466
SHOULD ANY OF THE ABOVE DESCRIBED POUCIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DEUVERED IN
Ashland Fire & Rescue ACCORDANCE WITH THE POUCV PROVISIONS.
466 Siskiyou Blvd AUTHORIZED REPRESENTATIVE
Ashland, OR 97620 ~ Jl/-LP
ACORD 25 (2009109)
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