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0 DATE(MM/DD/YYYY) <br /> AcoRo CERTIFICATE OF LIABILITY INSURANCE <br /> 10/16/2020 <br /> THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS <br /> CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES <br /> BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED <br /> REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. <br /> IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(les)must have ADDITIONAL INSURED provisions or be endorsed. <br /> If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on <br /> this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). <br /> PRODUCER CONTACT NAME: Susan Davidson <br /> Calrose Insurance Inc AIc°NIv Ex*_ 425-252-5188 A/c, <br /> No):425-339-9332 <br /> 2231 Broadway E-MAIL <br /> sue@calroseins.com <br /> Everett,WA 98201 INSURER(S)AFFORDING COVERAGE NAIC II <br /> INSURER A: Mutual of Enumclaw 14761 <br /> INSURED INSURER B: <br /> That Chicken Place LLC INSURER C: <br /> 1907 Hewitt Ave Ste A INSURERD: <br /> Everett,WA 98201 INSURER E: <br /> INSURER F: <br /> COVERAGES CERTIFICATE NUMBER: 00037075-43974 REVISION NUMBER: 3 <br /> THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD <br /> INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS <br /> CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, <br /> EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. <br /> INSR TYPE OF INSURANCE ADM SUBR POLICY EFF POLICY EXP LIMITS <br /> LTR INSD_VD POLICY NUMBER (MMIOD/YYYYI (MMIDDIYYYY) <br /> A X COMMERCIAL GENERAL LIABILITY Y BOP0017604 06128/2020 06/28/2021 EACH OCCURRENCE 5 1,000,000 <br /> DAMAGE TO RENTED <br /> CLAIMS-MADE X OCCUR PREMISES(Ea occurrence) S 100,000 <br /> MED EXP(Any one person) $ 10,000 <br /> PERSONAL&ADV INJURY $ <br /> GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE 5 2,000,000 <br /> X POLICY PROT LOC PRODUCTS-COMP/OP AGG S 1,000,000 <br /> JEC <br /> OTHER. $ <br /> AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT 5 <br /> (Ea accident) <br /> ANY AUTO BODILY INJURY(Per person) 5 <br /> OVvNED SCHEDULED BODILY INJURY(Per accident) <br /> AUTOS ONLY AUTOS <br /> HIRED NON-OWNED PROPERTY DAMAGE 5 <br /> AUTOS ONLY AUTOS ONLY (Per accident) <br /> 5 <br /> UMBRELLA LIAB _ OCCUR EACH OCCURRENCE 5 <br /> EXCESS LIAB CLAIMS-MADE AGGREGATE S <br /> DED RETENTIONS <br /> WORKERS COMPENSATION PER <br /> AND EMPLOYERS'LIABILITY STATUTE ERH <br /> ANY PROPRIETOR/PARTNER/EXECUTIVE Y/N NIA E.L.EACH ACCIDENT S <br /> OFFICER/MEMBER EXCLUDED? <br /> (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE S <br /> If yes,describe under <br /> DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT S <br /> DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached If more apace la required) <br /> City of Everett,its officers,employees and agents are named as an additonal for the duration of the program - Everett Care Act <br /> -BP04 48-additional insured-designated person form attached <br /> CERTIFICATE HOLDER CANCELLATION <br /> SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE <br /> THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN <br /> City of Everett ACCORDANCE WITH THE POLICY PROVISIONS. <br /> 1502 Rucker ave <br /> Everett,WA 98201 AUTHORIZED REPRESENTATIVE <br /> � Q'�JIJ (SGD) <br /> ©1988-2015 ACORD CORPORATION. All rights reserved. <br /> ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD <br /> Printed by SGD on October 16.2020 at 04:50PM <br />