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OREGON WORKERS COMPENSATION r` saiF
CERTIFICATE OF INSURANCE corporation
CERTIFICATE HOLDER:
CITY OF ASHLAND
20 E. MAIN STREET
ASHLAND, OR 97520
The policy of insurance listed below has been issued to the insured named below for the
policy period indicated. The insurance afforded by the policy described herein is subject to
all the terms, exclusions and conditions of such policy.
POLICY NO. POLICY PERIOD ISSUE DATE
488390 10/01/2011 to 10/01/2012 10/11/2011
INSURED: BROKER OF RECORD:
WELBURN ELECTRIC INC
PO BOX 329
PHOENIX, OR 97535-0329
LIMITS OF LIABILITY:
Bodily Injury by Accident $500,000 each accident
Bodily Injury by Disease $500,000 each employee
Body Injury by Disease $500,000 policy limit
DESCRIPTION OF OPERATIONS/LOCATIONS/SPECIAL ITEMS:
IMPORTANT:
The coverage described above is in effect as of the issue date of this certificate. It is subject to change
at any time in the future.
a
This certificate is issued as a matter of information only and confers no rights to the certificate
holder. This certificate does not amend, extend or alter the coverage afforded by the policies above.
AUTHORIZED REPRESENTATIVE
President and CEO
400 High Street SE
Salem,OR 97312
P:800.285.8525
F:503.373.8020
Policy_Batch_CertitlwteOflnsura nce