Laserfiche WebLink
1 <br /> State Farm® <br /> Business Insurance Fire Only) <br /> AdditionallInsured/C rtificate Holder Questionnaire <br /> Policyholder Na e: MAGO'S D EAM LLC DBA BODY&BRAIN Policy Number: 98-BT-B142-0 <br /> Agent: KATHE INE H DOVINF�INSURANCE AGENCY INC(47-2618) <br /> rsri <br /> Note—Please review the following and compare it to the request by the third party: <br /> A If the third party is only requesting Proof of Insurance please issue a Certificate of insurance(COI). A copy of the <br /> COI does not need to be sent to the operations center. <br /> ❑Check here If the third paryyis requesting Proof of Insurance, Certificate Holder Status,AND cancellation <br /> notice.Issue a COI, complete Part One only of this form and attach to an ECHO PT. There is no charge for <br /> Certificate NolderStatus. <br /> CI Check here if the third party <br /> is requesting Proof of insurance AND Additional Insured status. Issue a COI,complete <br /> Part One mid PartTwo of this form and attach to an ECHO PT. Additional Insured status may result in an additional <br /> premium c arge. One questionnaire per Additional Insured request is required. <br /> Part One: <br /> Third Party Name,Mailing Address,and Loan Number(if applicable): <br /> CITY OF EVERETT <br /> 2930 WETMORE A4E <br /> EVERETT.WA 98231 <br /> Does the third party need to receive a copy of the cancellation notice? Yes Qf No❑ <br /> II <br /> Part Two: <br /> Effective Date of the endorsement 10/19/202p End of Contract Date: 06/30/2025 <br /> What is the relationship between our Insured and Additional Insured? Describe the work or services being performed: <br /> Select ALL that apply for this Ad itional Insured Request: <br /> ❑Designated Person or Organisation (use:common general form for non-contractor requests and events/trade shows) <br /> :Designated Premises (use onl/if third party is regoesting) <br /> Choose all that apply to request: Section 10 Section 110 Loss of Income <br /> ❑Engineers,Architects or Surveyors- ,,BlanketO Scheduled❑ Primary Non-Contributory(not avail w/Bla iket)l <br /> ❑Grantor of Frahchise <br /> ❑Grantor of Lic nses—coverage defaults to Blanket,select Scheduled if desired Scheduled CI <br /> ❑ Lessor of Leas d Equipment Provide Lease Amount(not equipment value): <br /> ❑ Loss Payee— ust select oneiof the following: <br /> ❑Part A: Los Payable: Desqription/Interest: Loan Number: <br /> ❑Part B: Lender's Loss Payable:Description/Interest: Loan Number: <br /> ❑Part C: Contract of Sale D scription/Interest; Loan Number: <br /> ❑Managers or Lessors of Premi es (us <br /> efor Landl <br /> ords,lords not for use with property <br /> e managers) <br /> P rty m agers) <br /> ❑ Mortgagee,Asignee,or Rece ver-Primary Non!Contributory❑ <br /> ❑Owners,Lessees,or Contract rs (use:our insured is doing work for the Al) "Blanket❑ Scheduled 0 <br /> »State or Politigal Subdivisions)—Permits Choose one: For work® For Premises❑ 1 <br /> ❑ Vendor - Proyyide Annual SalFs: Product: <br /> 0 Other: <br /> Does the Al need to receive a copy of the declarations at issuance/renewal? Vest?, No❑ <br /> Does the policy need to be endorsed with a Waiver of Subrogation? Yes[ f No1:5 <br /> i <br /> Note:A Waiver of Subrogation cannot be allded to a blanket Al. A Waiver may be attached too scheduled Al specifically naming the entity to wh'ch it op lies. <br /> I <br /> Last Modified:7-17-19(bsnmj <br /> STATE FARM CONFIDENTIAL INFORMATION <br /> -Distribution on a Business Need to Know Basis Only— <br />