L.M. Sundholm Inc. PS 9/4/2020 - Laserfiche WebLink

1 ACORD® CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) ‘.....""--- 07/23/2020 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 CONTACT NAME: Ramona A.Heitzman Western Pacific Insurance Group PHONE 425 361-7454 FAX 425 949-3093 [A/C,No.ExU: ( ) (A/C,No): ( ) 16300 Mill Creek Blvd.Suite 208 E-MAILDDR rmona western aci com ADDRESS: @ P g• INSURER(S)AFFORDING COVERAGE NAIC# Mill Creek WA 98012 24082 INSURERA: OHIO SECURITY INSURED INSURER B: L.M.Sundholm,Inc.PS INSURER C: 10101 19th Ave SE Ste B INSURER 0: INSURER E: Everett WA 98208 INSURER F: COVERAGES CERTIFICATE NUMBER: 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 TYPE OF INSURANCE ADDL SUER POLICY EFF POLICY EXP LTR INSD WVD POLICY NUMBER (MM/DD/YYYY) (MM/DD/YYYY) LIMITS X COMMERCIAL GENERALA LIABILITY EACH OCCURRENCE $ 2,000,000 CLAIMS-MADE /� OCCUR DAMAGE TO RENTED PREMISES(Ea occurrence) $ 2,000,000 MED EXP(Any one person) $ 15,000 A X X BZS58883076 06/23/2020 06/23/2021 PERSONAL&ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 4,000,000 X PRO- POLICY JECT LOC PRODUCTS-COMP/OP AGG $ OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ (Ea accident) ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED BODILYINJURY(Peraccident $ AUTOS ONLY AUTOS ) HIRED NON-OWNED PROPERTY DAMAGE _ AUTOS ONLY _ AUTOS ONLY (Per accident) $ $ UMBRELLA UAB — OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION N/ PER OTH- AND EMPLOYERS'LIABILITY Y/N /"• STATUTE ER ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ 2,000,000 OFFICER/MEMBER EXCLUDED? N I A STOP GAP BP06740713 06/23/2020 06/23/2021 (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 2,000,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 2,000,000 A Optometrist Professional Liability X BZS58883076 06/23/2020 06/23/2021 Occurrence 2,000,000 Aggregate 4,000,000 DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space Is required) The City of Everett,its officers employees and agents are named as Additional Insured for the duration of the program. CERTIFICATE HOLDER CANCELLATION ATTN:Rebecca McCrary SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN City of Everett ACCORDANCE WITH THE POLICY PROVISIONS. 2930 Wetmore Ave.,Ste 8-A AUTHORIZED REPRESENTATIVE Everett WA 98201 fa.,61-/e"RE 0/ ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD