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The City of Portland, Oregon

Portland Bureau of Transportation

Phone: 503-823-5185

Fax: 503-823-7576

1120 SW Fifth Ave, Suite 1331, Portland, OR 97204

More Contact Info

Additional Insured Endorsement Form

"Without prejudice to coverage otherwise existing herein, the City of Portland and all other governmental bodies having jurisdiction in the area, their officers and employees are included as additional insureds under this policy as to any claim or claims for injury to person, including death, or damage to property, resulting from or in any way associated with the use of or presence at the street, area or facility to which the permit for

(name of event)

pertains, by the sponsor/applicant, its agents, employees, volunteers, event participants or spectators. This policy covers all claims by the sponsor/applicant, its agents, employees, volunteers, event participants or spectators against the City of Portland, members of the City Council, and the officers, agents and employees of the City.

"It is understood and agreed that this policy shall not terminate or be cancelled prior to completion of the event without first giving 30 days' written notice of intention to terminate or to cancel said policy to the Revenue Bureau."

"Notwithstanding the naming of additional insureds, the said policy shall protect each insured in the same manner as though a separate policy had been issued to each; but nothing herein shall operate to increase the insurer's liability as set forth elsewhere in the policy beyond the amount or amounts for which the insurer would have been liable if only one person or interest had been named as insured. The coverage must apply as to claims between insureds on the policy."

Permittee's Name

Signature of Authorized Insurance Company Representative



Please submit this form to: Allison Madsen, Special Events Program, City of Portland Revenue Bureau, 503-865-2482,

OFFICE USE: Date Received: _________________  Circle one:   ON TIME       LATE