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Client#: 129019 FORMCONS
<br /> ACORD„. CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY)11/10/2020
<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 /> in"D"RTANT:If the "rtifica+e hohl"r is ADrI1TIANAI Ir.1OI R.=^ the p"Ii"y(i".)...uct hne-Al5DITIIIIJAI !Mc]IPCf pr -isi *s r ke nA^rBn4_
<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 any rights to the certificate holder in lieu of such endorsement(s).
<br /> PRODUCER I
<br /> CONTACT Shatanna Hagen
<br /> Propel Insurance PHONE 800 499-0933 FAX 866 577-1326
<br /> (A/C,No,Ext): (A/C,No):
<br /> Tacoma Commercial Insurance EMAIL Shatanna.haen ro elinsurance.com
<br /> 1201 Pacific Ave,Suite 1000 ADDRESS: 9 @p p
<br /> INSURER(S)AFFORDING COVERAGE NAIC#
<br /> Tacoma,WA 98402 INSURER A:National Fire Insurance Company 20478
<br /> INSURED INSURER B:Travelers Property Casualty CoofAmerica 25674
<br /> Forma Construction Company
<br /> laany The Ohio CasualtyInsurance Company 24074
<br /> INSURER C: P Y
<br /> PO Box 11489
<br /> INSURER D:Illinois Union Insurance Company 27960
<br /> Olympia,WA 98508 _
<br /> INSURER E:
<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 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 /> ILTR I TYPE OF INSURANCE INSR VdVD'ADDCUBRi POLICY NUMBER ,(MM/DD/YYYY) (MM DDYY) LIMITS
<br /> A X COMMERCIAL GENERAL LIABILITY X X !6081320801 07/O9/2020,07/09/2021 EACH OCCURRENCE $1,000,000
<br /> _- D
<br /> CLAIMS-MADE X OCCUR 'I PREMISES(EO a occurrence) $300,000
<br /> X PD Ded:25,000 MED EXP(Any one person) $5,000-
<br /> PERSONAL&ADV INJURY $1,000,000
<br /> GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $2,000,000
<br /> PRO-
<br /> POLICY JECT LOC 1PRODUCTS-COMP/OP AGG $2,000 000
<br /> X �
<br /> OTHER:
<br /> $
<br /> T AU I VMUISILt LIAtlILI I T - f OMRINF[1 SINGLE I I�AIT
<br /> /q J( JC !6UB13LUYS15 V%%U9%2U2U U7/U`JJ2U21 (Ea accident) $1,000,U0U
<br /> X ANY AUTO BODILY INJURY(Per person) $
<br /> OWNED SCHEDULED
<br /> AUTOS ONLY AUTOS BODILY INJURY(Per accident) $
<br /> HIRED NON-OWNED I PROPERTY DAMAGE $
<br /> X AUTOS ONLY X AUTOS ONLY !. (Per accident)
<br /> -
<br /> $
<br /> B X UMBRELLA LIAB X OCCUR ZUP16N2556A2ONF 07/09/2020 07/09/2021 EACH OCCURRENCE -,.-_$10 000,000.
<br /> EXCESS LIAB CLAIMS-MADE AGGREGATE $10,000,000
<br /> DED RETENTION$ $
<br /> A WORKERS COMPENSAMON I'NA J[O(7 Gap 11//U`J/LVLU I U f lOyl LUL I !STATUTE l 1 ER
<br /> I PER I 1OTH-
<br /> AND EMPLOYERS'LIABILITY
<br /> Y-N ANY PROPRIETOR/PARTNERfEXECUTIVE 6081320801 E.L-EACH ACCIDENT $$1,000,000
<br /> OFFICER/MEMBER EXCLUDED? 1 N/A i
<br /> (Mandatory in NH) I E.L.DISEASE-EA EMPLOYEE $$1,000,000
<br /> I
<br /> If yes,describe under
<br /> DESCRIPTION OF OPERATIONS below ! [. E.L.DISEASE-POLICY LIMIT $$1,000,000
<br /> C XS over lead$1 OM 'ECO2161611766 07/09/2020 07/09/2021 $15,000,000 OCC
<br /> Umbrella . $15,000,000 AGG
<br /> D Pollution/Prof COOG23897854013 07/09/2020107/09/2022 $3,000,000 OCC/AGG
<br /> DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space is required)
<br /> Re: Job Order Contracting for the City of Everett-Year 3.
<br /> Additional Insured Status applies per attached form(s).
<br /> CERTIFICATE HOLDER CANCELLATION
<br /> ri+ of Everett SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE I
<br /> City o' THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
<br /> 3200 Cedar Street ACCORDANCE WITH THE POLICY PROVISIONS.
<br /> Everett,WA 98201
<br /> AUTHORIZED REPRESENTATIVE
<br /> ©1988-2015 ACORD CORPORATION.All rights reserved.
<br /> ACORD 25(2016/03) 1 of 1 The ACORD name and logo are registered marks of ACORD
<br /> nJ43V91 00;I:"4202567 "TDA"
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