Fillable Printable Certificate of Liability Insurance Form - Oregon
Fillable Printable Certificate of Liability Insurance Form - Oregon
Certificate of Liability Insurance Form - Oregon
ACORD
™
CERTIFICATE OF LIABILITY INSURANCE
DATE: (MM/DD/YY)
PRODUCER
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND
CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS
CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE
AFFORDED BY THE POLICIES BELOW.
INSURERS AFFORDING COVERAGE
INSURED
INSURER A: _____________________________________________________
INSURER B: _____________________________________________________
INSURER C: _____________________________________________________
INSURER D: _____________________________________________________
INSURER E: _____________________________________________________
COVERAGES
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. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
INSR
LTR
TYPE OF INSURANCE
POLICY
NUMBER
POLICY
EFFECTIVE
DATE
(MM/DD/YY)
POLICY
EXPIRATION
DATE
(MM/DD/YY)
LIMITS
GENERAL LIABILITY
00/00/2013
00/00/2014
EACH OCCURRENCE
$1,000,000
COMMERCIAL GENERAL LIABILITY
FIRE DAMAGE
(Any one fire)
CLAIMS MADE OCCUR
MED EXP
(Any one person)
_________________________________
PERSONAL & ADV
INJURY
_____________________________
GENERAL AGGREGATE
GEN’L AGGREGATE LIMIT APPLIES PER:
POLICY PROJECT LOC
PRODUCTS – COMP/OP
AGG
$
AUTOMOBILE LIABILITY
COMBINED SINGLE
$1,000,000
ANY AUTO
ALL OWNED AUTOS
SCHEDULED AUTOS
BODILY INJURY
(Per person)
$
HIRED AUTOS
NON-OWNED AUTOS
BODILY INJURY
(Per Accident)
$
________________________________
________________________________
PROPERTY DAMAGE
(Per accident)
$
GARAGE LIABILITY
AUTO ONLY
(Ea Accident)
$
ANY AUTO
OTHER
THAN
AUTO
ONLY:
EA
ACC
$
________________________________
AGG
$
EXCESS LIABILITY
EACH OCCURRENCE
$
OCCUR CLAIMS MADE
AGGREGATE
$
$
DEDUCTIBLE
$
RETENTION $
$
WORKER’S COMPENSATION AND
EMPLOYER’S LIABILITY
WC STATUTORY
LIMITS OTHER
E.L. EACH ACCIDENT
$
E.L. DISEASE –
EA EMPLOYEE
$
E.L. DISEASE – POLICY
LIMIT
$
OTHER
DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL
PROVISIONS but only with respect to the Contractors activities to be performed under this agreement: the State of Oregon, the Oregon Board of Forestry, the Oregon Department of
Forestry, Coos Forest Protective Association, Douglas Forest Protective Association, Walker Range Protective Association, the State of Washington, the Washington Department of Natural
Resources, the United States Forest Service (USFS), the National Parks Service (NPS), the Bureau of Land Management (BLM), the Bureau of Indian Affairs (BIA), the United States Fish &
Wildlife Service (USF&WS), Washington Association of Fire Chiefs; The Oregon Fire Chiefs Association, and their officers, divisions, agents, employees and members.
CERTIFICATE HOLDER
X
ADDITIONAL INSURED; INSURER LETTER
CANCELLATION
OREGON DEPARTMENT OF FORESTRY
PROTECTION PROGRAM
2600 STATE STREET
SALEM OR 97310
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE
EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 30
DAYS WRITTEN NOTICE TO THE CETIFICATE HOLDER NAMED TO THE LEFT, BUT
FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION LIABILITY OF ANY KIND UPON THE
INSURER, ITS AGENTS OR REPRESENTATIVES.
