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3. '3 DATE(MMIDDIYYYY)
<br /> A © CERTIFICATE OF LIABILITY INSURANCE 4/DATE(M 3
<br /> THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS
<br /> CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
<br /> BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED
<br /> REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER.
<br /> IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must be endorsed. If SUBROGATION IS WAIVED,subject to
<br /> the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the
<br /> certificate holder in lieu of such endorsement(s).
<br /> PRODUCER CONTACT ,,tl.-,I
<br /> NAME: MIchakHaL&Cot tpany_CALc rise#-0792445 ,
<br /> Michael J Hall&Company AinNw3
<br /> _#10R(1-S98-1700r [F4X,NO)=
<br /> 19660 10th Ave NE E-MAIL.
<br /> Poulsbo WA 98370 ADDREss:ceitifil ayes@haElendcamoany.e&M ,
<br /> INSURER(S)AFFORDING COVERAGE NAIC#
<br /> INSURER A:T1I,,-e.Tra_VRIPrs Indem(1if C.OrTiDany 25,F:11
<br /> INSURED 282 INSURER B:Th_P(.h.rter nAK Fire Insurance Comp 2 6j5
<br /> KPG Inc INSURER C IINfF)?WRITFRSAT LLOYDS LONDON. It57?? i
<br /> 753 9th Avenue North INSURER D:
<br /> Seattle WA 98109
<br /> INSURER E: '
<br /> INSURER F:
<br /> COVERAGES ' CERTIFICATE NUMBER:1002562048 REVISION NUMBER:.
<br /> THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
<br /> INDICATED, NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
<br /> CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,
<br /> EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.
<br /> jLIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
<br /> LTR 'TYPE OF INSURANCE (NSR I WVD POLICY NUMBER I(MMIDCI POLICY EFF
<br /> (MMIO YDIYYYY)EXP I LIMITS
<br /> A GENERAL UABIUTY 5803947N451 3/1/2012 5/1/2013 EACH OCCURRENCE $1,000,000
<br /> --DAMAGE TO RuYE6-
<br /> X COMMERCIAL GENERAL LIABILITY PREMISES(Ea occurrence) $300,000
<br /> _ l CLAIMS-MADE lX 1 OCCUR MED EXP(Any one person) $5,000
<br /> X XCU/OCP/BFPD PERSONAL&ADV INJURY $1,000,000
<br /> _
<br /> X Cross Liability GENERAL AGGREGATE $2,000,000
<br /> GEN'L AGGREGATE LIMIT APPUES PER: - PRODUCTS-COMPIOP AGG $2,000,000
<br /> —1 POLICY IX 11JE (1 LOG S
<br /> B AUTOMOBILE LIABILITY • BA4011 N714 5/1/2012 3/1/2013 _re dtsat�INGt E LIMIT 1 000,000
<br /> { X ANY AUTO BODILY INJURY(Per person) $
<br /> ALL OWNED [SCHEDULED BODILY INJURY(Per accident) $
<br /> AUTOS NON-OWNED PROPERTYPrDAMAGE $ ;
<br /> HIRED AUTOS AUTOS (Per --
<br /> _.-__ S
<br /> A X UMBRELLA LIAR X OCCUR CUP3779T032 3/1/2012 5/1/2013 EACH OCCURRENCE $5,000,000
<br /> _____ —~
<br /> EXCESS LIAB CLAIMS-MADE AGGREGATE $5,000,000
<br /> DED RETENTION$ $
<br /> pt WORKERS COMPENSATION' $803947N451 b/1/2012 '3/1/2013 T ST AN-IX a R- WA Stop Gap
<br /> AND EMPLOYERS'LIABILITY
<br /> ANY PROPRIETOR/PARTNERIEXECUTIVE Y/N NIA EL,EACH ACCIDENT $1,000,000
<br /> OFFICER/MEMBER EXCLUDED?
<br /> (Mandatory In NH) EL DISEASE-EA EMPLOYEE $1,000,000
<br /> If yes,desenbe under
<br /> DESCRIPTION OF OPERATIONS below E DISEASE-POLICY LIMIT I$1,000,000
<br /> C Professional Liab Claims Made 1147823385/012 3/1/2012 3/1/2013 $1,000,000 Per Claim Retro Date:
<br /> $1,000,000 Aggregate June 1,1994
<br /> DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(Attach ACORD 101,Additional Remarks Schedule,If more space is required)
<br /> Certificate Holder(s)is/are an Additional Insured on the Commercial General Liability and Auto Liability when required by written contract or
<br /> agreement regarding-apt-Wes by or on behalf of the Named Insured.The Commercial General Liability insurance is primary insurance and
<br /> any other insu'rance'maintained by the Additional Insured shall be excess only and non-contributing with this insurance.A waiver of
<br /> subrogation applies.to`the Commercial General Liability,Auto Liability,Umbrella/Excess Liability and Workers Compensation/Employers
<br /> Liability in favor of the Additional Insured.
<br /> Project/Job Name:13038 Shore Avenue Stormwater Outfall Improvements
<br /> CERTIFICATE HOLDER CANCELLATION
<br /> SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
<br /> THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
<br /> City of Everett ACCORDANCE WITH THE POLICY PROVISIONS.
<br /> Attn: Heather Griffin
<br /> 3200 Cedar Street AUTHORIZED REPRESENTATIVE
<br /> Everett WA 98201 C'-
<br /> TH '
<br /> Z 7, ,e
<br /> ).
<br /> ©1988-2010 ACORD CORPORATION. All rights reserved.
<br /> ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD
<br /> . 28 i
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