Loading...
HomeMy WebLinkAboutInsurance Certificate: Potelco Inc ® DATE(MMIDDIY )1`1 A� CERTIFICATE OF LIABILITY INSURANCE 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(les)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 John L. Wortham & Son, L.P. CONTACT NAME: P. O. BOX 1388 PHONE INC No,Eu. 713-526-3366 FAX I Arc NA: 713-521-1951 Houston, TX 77251-1388 EWAIL ADDRESS: INSURERS AFFORDING COVERAGE NAIC 0 INSURER A: Old Republic Insurance Company 24147 INSURED Potelco: Inc. INSURER B: Ace Property&Casualty Insurance Co. 20699 14103 Stewart Rd' NSURER C: Sumner WA 98390 INSURER D INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: 10659678 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 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.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCE ADOL SUER POLICY NUMBER MMIDDYIYYYY MMIODYf/YXYY LIMITS LTR A GENERAL LIABILITY MWZY59308 8/112011 8/1/2012 EACH OCCURRENCE $ 5,000,000 DAMAGE TO RENTED 5,000,000 COMMERCIAL GENERALUABILITY PREMISES EaePCUnd.. S CLAIMS-MADE rvl OCCUR MED EXP(Any one person) $excluded PERSONAL&ADV INJURY S 5,000,000 GENERAL AGGREGATE S 5.000,000 GENT.AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OPAGG $ 5,000,000 POLICY 7 PRO LOC $ JECT A AUTOMOBILE LIABILITY MWTB21321 8/112011 81112012 COMBINED SINGLE IN L LIMIT $ 50 0000 ANY AUTO BODILY INJURY(Per Person) $ ALL AUTOS OWNED SCHEDULED BODILY INJURY(Per aoddont) S UTOS NON-OWNED PROPERTY DAMAGE HIRED AUTOS AUTOS Per awident E E $ B UMBRELLA LIAB U OCCUR XOOG25908971 8/1/2011 8/1/2012 EACH OCCURRENCE $ $000000 EXCESS LIAR 1/ CLAIMS-MADE AGGREGATE E 5,000,000 DED � RETENTION$per policy CM Retro Date 8/112002 $ µ $ TATU- A WORKERS COMPENSATION MWC11713400 8/1/2011 8/1/2012 TORY LIMITS OER AND EMPLOYERS'LIABILITY YIN My OFFICERIIAEMBER EXCLUDED?ECUTIVE NIA E.L.EACH ACCIDENT E 1,000,000 (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $ 1 00000 If yea describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 1.000,000 D DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101,Additional Remarks Schedule,N more space Is mqulmd) 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 City Of Ashland, Oregon THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Attn: Kan Ann Olson ACCORDANCE WITH THE POLICY PROVISIONS. 90 N. Mountain Ave. Ashland OR 97520 AUTHOR ZED REPRESENTAT VE John L.Wortham&Son,L.Pjavt. ©1988.2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010105) The ACORD name and logo are registered marks of ACORD CERT NO.: 10659678 CLIENT CODE: 1000ANTSER MOM Sandy Moo[e 7/13/2D11 9:56:29 AM Pala 1 of 3 CERTIFICATE ADDENDUM DATE ISSUED 7/13/2011 NAMED INSURED: CERTIFICATE HOLDER: Potelco, Inc. The City Of Ashland, Oregon 14103 Stewart Rd. Attn: Karl Ann Olson Sumner WA 98390 90 N. Mountain Ave. Ashland OR 97520 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,WE WILL ENDEAVOR TO MAIL 30 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER(S)NAMED ON THIS CERTIFICATE,EXCEPT FOR NON-PAYMENT OF PREMIUM OR ANY OTHER CIRCUMSTANCE PERMITTED BY STATE LAW OR POLICY CONDITIONS.FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON US. eceMSonline^ CERTIFICATE ADDENDUM C£RT NO.: 10659670 CLI= CODE: 1000A SER (NOU) Sandy Mooie 7/13/3011 9:56:39 AM Page 2 of 3 CERTIFICATE ATTACHMENT 7/ 11 7/11 3/203/2011 NAMED INSURED: Potelco, Inc. 14103 Stewart Rd. Sumner WA 98390 General Liability policy includes aggregate limits of insurance per project subject to a maximum policy aggregate of $20,000, 000. acanson6nen, CERTIFICATE ATTACHMENT CERT NO.: 10659676 CLIENT CODE: 1DQU N SER (HOU) Sandy Moore 7/13/2011 9:56:24 AM Page 3 of 3 Joh11 L.Worth'em&Son,L.P. P.O.Box 1388 Houston,TX 77251-1388 MAIL DOCUMENT Certificate of Insurance Delivery by ecertsonline TN Sender: (HOU)Sandy Moore The City Of Ashland, Oregon Phone: 713-5zs-33ss Attn: Kari Ann Olson 90 N. Mountain Ave. ACORD 25(05110)Certificate or Liability:Quanta Ashland OR 97520 Subject: Services,Inc. Date: 7/13/2011 No. of Pages: 4 URL: THIS MESSAGE IS INTENDED FOR THE USE OF THE INDIVIDUAL OR ENTITY TO WHICH IT IS ADDRESSED AND MAY CONTAIN INFORMATION THAT IS PRIVILEGED,CONFIDENTIAL AND EXEMPT FROM DISCLOSURE UNDER APPLICABLE LAW.IF THE READER OF THE MESSAGE I$NOT THE INTENDED RECIPIENT,OR THE EMPLOYEE OR AGENT RESPON BIBLE FOR DELIVERING THE MESSAGE TO THE INTENDED RECIPIENT,YOU ARE HEREBY NOTIFIED THAT ANY DISSEMINATION,DISTRIBUTION OR COPYING OF THIS COMMUNICATION IS STRICTLY PROHIBITED.IF YOU HAVE RECEIVED THIS COMMUNICATION IN ERROR,PLEASE NOTIFY US IMMEDIATELY BY TELEPHONE,AND RETURN THE ORICINAL MESSAGE TO US AT THE ABOVE ADDRESS VIA REGULAR POSTAL SERVICE. 0 2002 Cert ificate of Insurance Delivered by ecertSOnlin TM Insurance Visions,Inc.All rights reserved.