2017-717-E EMS - Excellance ambulance mounting agreement

Browse Search

DocuSign Envelope ID: FF75FEC8-F41A-4602-AD91-CF4E1D20F117 fl AC40RO® CERTIFICATE OF LIABILITY INSURANCE FDATE(MMIDDIYYYY) ��. 8/2/2017 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). ACT PRODUCER NAME: NAME: Cleonie Nathanielsz JD Fulwiler & Co. Insurance, Inc. PH No.L•rl):_ (503)293-8325 FAX,Nul:(503)293-5418 JC.5727 SW Macadam Ave ADDR_ESS.:cnathanielsz@jdfulwiler.com PO BOX 69508 INSURER(S)AFFORDING COVERAGE NAICN Portland OR 97239 INSURERA:National Fire Insurance of Hartford � 20478 INSURED INSURER e:Continental Insurance . 35289 Excellance Inc INSURERC: 453 Lanier Rd INSURER D: INSURER E: Madison AL 35758 1 INSURERF: COVERAGES CERTIFICATE NUMBER:CL178148230 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. IN TYPE OF INSURANCE INSD I WUVO POLICY NUMBER MM DDYIYYYY MM BDIIYYYY LIMITS .bD X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 DAMAut Tu KLN I eu 300,000 A CLAIMS-MADE I X_I OCCUR PREMISES(Ea occurrencel _$ � 6042861810 8/1/2017 8/1/2018 MED EXP(Any one person) $ 15,000 PERSONAL&AD_V INJURY S 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 _ PRO- ❑ LOC PRODUCTS-COMP/OP AGG 8 2,000,000 X POLICY JECT — OTHER: Employee Benefits $ 1,000,000 COMBAUTOMOBILE LIABILITY Ea accident)SINGLE LIMIT $ 1,000,000 X ANY AUTO BODILY INJURY(Per person) $ A ALL OWNED I SCHEDULED AUTOS AUTOS 6092861807 8/1/2017 B/1/2018 BODILY INJURY(Per accident) $ NON-OWNED PROPERTY DAMAGE $ X HIRED AUTOS X AUTOS (Per.apCidtnt). Medical payments $ 5,000 X UMBRELLA L1AB OCCUR EACH OCCURRENCE $ 9,000,000 B EXCESS LIAB CLAIMS-MADE AGGREGATE $ 9,000,000 DED I X RETENTIONS 10,000 6042861824 8/1/2017 8/1/2018 I $ WORKERS COMPENSATION PER R YIN AND EMPLOYERS'LIABILITY STATUTE ER ER ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ OFFICERIMEMBER EXCLUDED? NIA (Mandatory in NH) E.L DISEASE-EA EMPLOYEE $ IF yes,describe under DESCRIPTION OF OPERATIONS below _ E.L.DISEASE-POLICY LIMIT $ I I I I I DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached it more space is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE PROOF OF INSURANCE ONLY THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE Becky Harding/CLEONI ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD INS025(201401)