N Anne Almgren 12/3/2019 - Laserfiche WebLink

ACoDATE(MM/DD/YYYY) REP CERTIFICATE OF LIABILITY INSURANCE 10/3/2019 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 have ADDITIONAL INSURED provisions or 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). PRODUCER Liberty Mutual Insurance NAMEACT PO Box 188065 PHONE FAX Fairfield, OH 45018 IANC.IL Ext); 800-962-7132 (A/C,No): 800-845-3666 E-MAIL BusinessService©LibertyMutual.com INSURER(S)AFFORDING COVERAGE NAIC# INSURER A: Ohio Security Insurance Company 24082 INSURED INSURER B: Anne Almgren 4111 164th St SW Unit 61 INSURER C: Lynnwood WA 98087 INSURERD: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: 51623058 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. INSR LTR TYPE OF INSURANCE IN SD SUBR POLICY NUMBER /YPOLICY EFF POLICY EXP LIMITS (MM/DDYYY) (MM/DD/YYYY) A i COMMERCIAL GENERAL LIABILITY ✓ BZS54964073 11/16/2019 11/16/2020 EACH OCCURRENCE $1,000,000 DAMAGE TO CLAIMS-MADE ✓ OCCUR PREMISES(Ea occurrence) $1,000,000 ✓ Businessowners MED EXP(Any one person) $15,000 PERSONAL&ADV INJURY $1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $2,000,000 ✓ POLICY JECT LOC PRODUCTS-COMP/OPAGG $2,000,000 OTHER: $ A AUTOMOBILE LIABILITY BZS54964073 11/16/2019 11/16/2020 (EaaccdeDtINGLELIMIT $1,000,000 _ ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS HIRED NON-OWNED PROPERTY DAMAGE $ ✓ AUTOS ONLY ✓ AUTOS ONLY (Per accident) UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ A WORKERS COMPENSATION BZS54964073 11/16/2019 11/16/2020 SPER TATUTE 0TH AND EMPLOYERS'LIABILITY Y/N ANYPROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $1,000,000 OFFICER/MEMBEREXCLUDED? NIA (Mandatory in NH) /stoGa E.L.DISEASE-EA EMPLOYEE $1,000.000 If yes,describe under p p DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $1,000,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) Carl Gipson Senior Center is Additional Insured if required by written contract or written agreement,subject to Businessowners'Liability Extension Blanket Additional Insured Provision. CERTIFICATE HOLDER CANCELLATION Carl Gipson Senior Center SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Carl ipson et THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Everett WA 9St ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE 4 Wrikk Alicia Smith ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD 51623058 1 54964073 1 19-20 Master Certificate 1 Alicia Smith 110/3/2019 10:21:19 AM (EDT) 1 Page 1 of 5