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Home My WebLink AboutPermit Correspondence 1992-10-9 OCT 9 1992 0 CERTIFICATE AS TO EVIDENCE OF INSURANCE (Special ?eotinel Policy) (PRIMARY . . INSURANCE e Exchange or Company shown on the ~rse side as number ( ~~J~CE) Excess over Primary with Company shown on reverse side as number 2 nECE.IIJ;:D . """~""'T~'T'i'r: Si:o,nj"ltl'" i ,'}lil!l'l10 f\J\ 'h':' :...1\ r1VI(X) . lHlS IS NOT AN INSURANCE poutW ~ IS ONLY A VERFICATION OF INSURANCE, IT DOES NOT IN ANY WAY AMEND, EXTEND OR ALTER THE COVERAGE PROVIDED BY THE POLICIES LISTED BELOW Named GEORGE & LINDA CLOUD Insured DBA: WHITE CLOUD JEWELERS Address 715 MAIN ST. SPRINGFIELD, OR. 97477 Excess Policy or Certificate No. 73-18-344 I 03491-00-82 Agent Policy Number We certify that policies for the above Named Insured are in force as follows: Effective from: 09-14-92 to' certificate becomes void or [Xl continuous until cancelled if box "X'd". 'It which time this BUSINESS LIABILITY COMBINED PRIMARY & EXCESS LIMITS OF INSURANCE III Covered Business Liability - including Products - completed operations $ 1,000,000 Fire Legal Liability $ 75,,000 Medical Payments to others $ 5,000 Non-Owned Automobile $ 1,,000,,000 Combined Annual Aggregate of the above coverages $ 1,000,000 * . o Covered IX] Not Covered Professional Liability Annual Aggregate $ NIL UMBRELLA LIABILITY POlicy Number Umbrella Liability $ $ $ ,000 retained limit ,000 each occurrence ,000 Annual aggregate Upon cancellation or termination of this policy.or policies from any cause we will mail 30 the other interest shown below, Notice of cancellation of the primary coverage automatically terminates excess coverage, Certificate issued To: rJays written notice to Named and Address CITY OF SPRINGFIELD 225 NORTH 5TH STREET SPRINGFIELD" OR. 97477 Countersigned Date By Authorized Representative . This certificate supersedes any previously issued certificate, 5&5306 1ST EDmON 8-91 1201 -- T6VER) A , ...,-~. ..... ..'. ';0,. . The following are inter-insurance exchanges sometimes referred in the policy when issued by either of them, as Company, 1, Farmers Insurance Exchange Los Angeles, California 2. Truck Insurance Exchange Los Angeles, California The following is a stock company referred to in the policy, when issued by it, as the Company, 3. Mid'Century Insurance Company Los Angeles, California 4, L1oyds, London and/or Companies in England c/o G, J, Sullivan Co, Los Angeles, California 5, Other 5&5306 1ST EDmON -;'v,. -- \j . . . A INTI;u~~I~~~~~~~g~E~~~~.~~;,CE:U " '"~ THIS IS NOT AN INSURANCE POLICY, THIS IS~Y A V~RI~'Cr~ON OF INSURANCE, IT ~~~~/~~1~~~ ~~'~~~~D, EXTEND OA ALTER THE COV~:':~ PROVIDED BY THE POLICIES LISTED BELOW, ~ I: P 1 6 1992 Insured G€.OtU,tE +- /-,NOfj ~L{O () 34q/~ 00-8"2- Addre.. O~A Wf-i IT~ C/.-vu{) J'GW6t..6f/.,S J-" 11_" 110 p""",'.Goo,U'b, l/J-Jn ";''''''1 7/S Mt! I rI Sf I Agent po,"",'.A,'oL;'b, S"PtL/,v6 f/l~t-O 0 t<.. '171.(,7 This is to certify that policies for the above named iiiSured are in force as fOllows: . Policy Ii . Work Comp. This Interim Certifirate As To Evidence of Insurance shall expire sixty days from 11..: a' AM., ' q . I tJ , 19 L1:-trnless cancelled prior to such date by written notice to the named insured. ~ Please issue a Permanent Certificate COVERAGE NOT COVERED ~ Owned [B Hired IE Non-Owned [B. Employer's Non-Qwnership Contingent Liability COVERED D D D D Policy Ii . CARGO COMBINED LIMITS OF LIABILITY AUTO LIABILITY Bodily Injury $ $ $ ,000 each parson ,000 each occurrence ,000 each occurrence Property Damage Single Limit Liability for Coverages checked IX! above ~ ~ $ ,000 eech occurrence D o GENERAL LIABILITY , M&C - OL T Owners & Contractors Contractual * , Elevators Products and I or Completed Operations Property Damage $ $ $ $ $ $J}OOG $ I i O"Ci $ $ Bodily Injury ,000 each parson * * ,000 eech occurrence 000 annual aggreoate I products * * * ,000 each occurrence ,000 ~~~ct:gf"al* Single Limit Liability for Coverages checked !Xl above o ,000 each occurrence 000 onnual aggregate I products * * * o CARGO ,000 each vehicle ,000 each occurrence o 0 co:~:~~~;ON Statutory * Includes Goods or Products Warranty, Written Lease of Premises, Easement Agreement, Municipal Ordinance Agreement: Sidetrack AQreement1 Elevator or Escalator Maintenance Agreement only, unless accompanied by specific enaorsement providing additional Contractual Coverage. D=- 0=". OWNED AUTO- MOBilES, IF COVEREO " YEAR. MAKE. TYPE OF BODY. LOAD CAPACITY IDENTIACATION NUMBER lAST 3 DIGITS SHOWN POLICY NUMBER Umbrella Liability ,000 retained limit each occurrence eggregete $ $ $ If the Interim Certificate As To Evidenc~ Of Insurance is to be cancelled prior to the expiration date, we shall provide days advance notice in writing to whom this certificate is issued. VENN VRANAS FARMERS INSURANCE GROUP 870 WEST CENTENNIAL SPRINGFIELD, OR 97477 Lease I Loen (W) 741.2280 (H) 485-4469 Number Certificate issued to: err-v or: S(JI2-III/GF'~'-E 21.-5 No, s+h SI _ ..,--- SPI2-itJGPle~f)/ OA.. "171177 Countersigned ---vu~" t . /Authorlzed Representatlvo * * Not Applicable in Texas. ' "," .~ V * * * In Texas the aggregate also applies to owners and contractors protective, contractual and I or completed operations. 56-05142-90 1651 W/200 Cf1200 Name And Address l.g111551