2014/05/28 Council Agenda Packet

OP ID: EF c-cw' CERTIFICATE OF LIABILITY INSURANCE THIS S 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). PRODUCER Biggs Insurance Services P.O. Box 189 916 Main Street Vancouver, WA 98666 Jon Courser INSURED Western Display Fireworks,Ltd. P.O. Box 932 Canby, OR 97013 Phone: 360-695-3301 Fax: 360-696-2232 CUNIALI NAME: i DATE (MM1DDfYYYY) 05115114 PHONE (NC. No, Ext): E-MAIL ADDRESS: FAX (AIC, No): PRODUCER WESTE-5 CUSTOMER ID $: INSURER(S) AFFORDING COVERAGE INSURER A: Liberty Surplus Insurance Comp INSURER B :James River Insurance Company INSURER C:Hudson Insurance Company INSURER D : INSURER E : INSURER F : NAIC # 25054 • .�., .-...--•.•__... CERTIFICATE NUMBbl :THIS COVERAGES BOVE E BEEN ISSUED TO THE INSURED NMED CE LISTED IS TO INDICATED. CNOTWITHSTANDING OANY IREQUIREMENNT, TERM OR CONDITIONVOF ANY CONTRACT OR OTHER DOCUMENTAFOR 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. • ILTR OF INSURANCE1NSI? ADDL SUBR WVD POLICY NUMBER POLICY EFF (MMIDDIYYYY) POLICY EXP IMMIDD(YWY1 LIMITS GENERAL LIABILITY COMMERCIAL GENERAL LIABILITY X OCCUR X 100000139710PREMISES 01115114 EACH OCCURRENCE $ 1,000,00C 01/15/15 DAMAGE I KEN IED (Ea occurrence) $ 50,00C A X MED EXP (Any one person) $ Excludec CLAIMS -MADE PERSONAL & ADV INJURY $ 1,000,00C GENERAL AGGREGATE $ 2,000,00C X Stop Gap PRODUCTS - COMP/OP AGG $ 1,000 OOC GEN'L AGGREGATE LIMIT APPLIES PER: $ I r�r'�I I POLICY ) 5 1 Pi Q'TT I LOC C AUTOMOBILE LIABILITY ANY AUTO ALL OWNED AUTOS SCHEDULED AUTOS HIRED AUTOS NON -OWNED AUTOS BU 100301600 INCLUDING TRUCKERS 01/15114 , 01/15/15 COMBINED SINGLE LIMIT (Ea accident) $ 1,000,00C X BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ PROPERTY DAMAGE (Per accident) $ X X $ X UMBRELLA LIAB X OCCUR CLAIMS -MADE 000514652 01/15/15 EACH OCCURRENCE $ 4,000,00C AGGREGATE $ 4,000,00001/15/14 X EXCESS LIAB INCLUDES $ DEDUCTIBLE TRUCKERS $ AND AUTC $ WORKERS AND ANY OFFICER1MEMBER (Mandatory If yes, RETENTION COMPENSATION EMPLOYERS' LIABILITY PROPRIETORIPARTNERIEXECUTIVE EXCLUDED? in NH) describe under Y 1 N N 1 A WC STATU- OTH- TORY LIMITS ER E.L. EACH ACCIDENT $ ■ E.L. DISEASE - EA EMPLOYEE $ below E.L. DISEASE - POLICY LIMIT $ D DESCRIPTION OF OPERATIONS DESCRIPTION Show Everett, officers, 4) OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required) Date: July 4, 2014 Site: Barge located 850 feet east of Jetty Island, WA 98201 Additional insured per CG2010 1) City of Everett, its employees and agents 2) Everett July Fourth Foundation 3) Cemex Island Tug CERTIFICATE HOLDER EVER086 Everett July Fourth Foundation 2930 Wetmore Ave., Suite 10-A Everett, WA 98201 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE ACORD 25 (2009109) © 1988-2009 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD 37