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A4 O® DATE(N1/DD/YYYY) <br /> �- CERTIFICATE OF LIABILITY INSURANCE 071242020 <br /> ^ 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 <br /> AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE ACONTRACT BETWEEN THE ISSUING 1NSURER(S), <br /> AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. <br /> IMPORTANT:If the certificate holder is an ADDITIONAL INSURED,the polcy(Les)must have ADDITIONAL INSURED provisions or be endorsed.IfSUBROGATION IS WAIVED,subject to the terms and <br /> 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). <br /> PRODUCER CONTACT <br /> NAME: Monica Baldoceda <br /> Baldoceda Insurance Agency PHONE FAX <br /> 13030 Linden Ave N Ste A (A/C,NO,EXT):206-783_6664 (A/C,NO):206-783-6665 <br /> E-MAIL <br /> See WA 98133-7587 ADDRESS: <br /> INSURER(S)AFFORDING COVERAGE NAIC# <br /> INSURED INSURER A Truck kIStiaice Exchange 21709 <br /> INSURER B: Fanners Insurance Exchange 21652 <br /> MARIMBA RESTAURANT LLC INSURER C: MkI Century kntrance Company 21687 <br /> 1405 HEWITT AVE <br /> INSURER D: <br /> INSURER E: <br /> EVERETT WA 98201 <br /> INSURER F. <br /> COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: <br /> THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAME ABOVE FOR THE POLICY PERIODINDICATED.NOTWITHSTANDING ANY <br /> 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 <br /> POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. <br /> INSR TYPE OF INSURANCE ADDTL SUBR POLICY NUMBER POLICY EFF POLICY EXP LIMITS <br /> UR INSR MID (MM/Dorrrn) (MM/DoPron) <br /> X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 <br /> DAMAGETO RENTED <br /> CLAIMS-MADE X OCCUR <br /> PREMISES(Ea Occurrence) $ 75,000 <br /> 1 MED EXP(My one person) $ 5,000 <br /> B ti134677910 09106/2019 ' 09106 2020 PERSONAL&ADV INJURY $ 1,000,000 <br /> GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 <br /> X POLICY PROJECT LOC PRODUCTS-COMP/OP AGG $ 2,000,000 <br /> I <br /> OTHER: i $ <br /> AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ <br /> (Ea accident) <br /> ANY AUTO BODILY INJURY(Per person) $ <br /> B OWNED AUTOS SCHEDULED BODILY INJURY(Per accident)$ <br /> ONLY AUTOS 604677910 0910612019 0910612020 <br /> HIRED AUTOS X NON-OWNED PROPERTY DAMAGE $ <br /> X ONLY AUTOS ONLY 1 (Per accident) <br /> $ <br /> UMBRELLALWB OCCUR EACH OCCURRENCE $ <br /> EXCESS LIAB CLAIMS-MADE AGGREGATE $ <br /> DED RETENTION$ $ <br /> WORKERS COMPENSATION PER OTHER $ <br /> AND EMPLOYERS'LIABILITY STATUTE <br /> ANY PROPRIETOR/PARTNER/ Y/N E.L EACH ACCIDENT $ <br /> EXECUTIVE OFFICER/MEMBER N/A <br /> EL DISEASE-EA EMPLOYEE I <br /> EXCLUDED?(Mandatory in NH) <br /> If yes,describe under DESCRIPTION OF EL DISEASE-POLICY LIMIT $ <br /> OPERATIONS below <br /> DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,maybe attached if more space is required) <br /> City of Everett,Ns ofNcers,employees and agents <br /> CERTIFICATE HOLDER CANCELLATION <br /> City of Everett SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION <br /> 2930 Wetmore Avenue DATE THEREOF NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. <br /> Everett,WA 98201,USA AUTHORIZED REPRESENTATIVE hrie g <br /> ale jeczelez <br /> ACORD 25(2016/03) ©1988-2015 ACORD CORPORATION.All Rights Reserved <br /> 31-1769 11-15 The ACORD name and logo are registered marks of ACORD <br />