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HomeMy WebLinkAboutInsurance Certificate: Grayback Forestry Inc (2) ® CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDD YYYY) ACORO 1/4/2012 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 CONTACT NAME: KPD Insurance, Inc. PHONE FAX AC No: PO BOX 784 EMAIL Springfield OR 97477 ADDRESS: INSURERS AFFORDING COVERAGE NAIL If INSURER A INSURED GRAY03W INSURER B:Z ri Annerican Insurance Co Grayback Forestry, Inc. INSURER C: PO Box 838 INSURER D: Merlin OR 97532 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER:2064671231 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 ADDL SUBR POLICY EFF POLICY EXP LIMITS LTR TYPE OF INSURANCE I POLICY NUMBER MMIDDIYYYY MMIDD/YYYY GENERAL LIABILITY EACH OCCURRENCE $ D COMMERCIAL GENERAL LIABILITY PREMISES R cc Dn $ CLAIMS-MADE ❑OCCUR MED EXP Any one perso n I $ PERSONAL B ADV INJURY $ GENERALAGGREGATE $ GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGO $ POLICY PRO LOC $ JFCT AUTOMOBILE LIABILITY Ea accident ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS NONOWNED PROPERTY DAMAGE $ HIRED AUTOS AUTOS Per accident UMBRELLA LIAR HOCCUR EACH OCCURRENCE $ EXCESS LAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ S A WORKERS COMPENSATION 95606 7/1/2012 /1/2013 X WCSTATU- OTH- AND EMPLOYERS'LABILITY Y ANY PROPRIETOR/PARTNERIEXECUTIVE❑ NIA E.L.EACH ACCIDENT $500,000 OFFICER/MEMBER EXCLUDED? (Mandatory in NH) - E.L.DISEASE-EA EMPLOYEE $500,000 It yes,describe under DESCRIPTION OF OPERATIONSbelow E.L.DISEASE-POLICY LIMIT $500,000 B Workers Compensation C9663291 111/2012 11/2013 EL Each Accident $1,000,000 and Employers Liablity Limits EL Disease EA $1,000,000 EL Disease Policy $1,000,000 DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES (Attach ACORD 101,Additional Remarks Schedule,If more space Is required) Re:All Operations CERTIFICATE HOLDER CELLATION ANY OF- 9 2012 EXPIRATIIONH E DATE VTHEOF,ENOTIICEI WILL CBECDELIVERED R JAN BE IN IN City Of Ashland JE OULD CORDANCE WITH THE POLICY PROVISIONS. 20 East Main Street Ashland OR 97520 AU#iOFUZED REPRESENNTTA,TTI,VEIM ©1988.2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010105) The ACORD name and logo are registered marks of ACORD