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Client#: 129019 FORMCONS
<br />ACORDTM CERTIFICATE OF LIABILITY INSURANCE
<br />DATE (MM/DD/YYYV)
<br />9/02/2021
<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(tes) 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 any rights to the certificate holder in lieu of such endorsement(s).
<br />PRODUCER
<br />Propel Insurance
<br />Tacoma Commercial Insurance
<br />1201 Pacific Ave, Suite 1000
<br />Tacoma, WA 98402
<br />NAMEACT Shatanna Hagen
<br />PHONE 800 499-0933
<br />(A/C, No, Ext):
<br />X
<br />(NC, No): 866 577-1326
<br />n DREss: shatanna.hagen@propelinsurance.com
<br />INSURER(S) AFFORDING COVERAGE
<br />INSURER A: National Fire Ins Co of Hartford
<br />NAIC #
<br />20478
<br />INSURED
<br />Forma Construction Company
<br />500 Columbia St NW, Suite 201
<br />Olympia, WA 98501
<br />INSURER a : Travelers Property Casualty CoofAmerica
<br />25674
<br />INSURER C: The Ohio Casualty Insurance Company
<br />24074
<br />INSURER D: Illinois Union Insurance Company
<br />27960
<br />INSURER E : Valley Forge Insurance Company
<br />20508
<br />INSURER F :
<br />CERTIFICATE NUMBER:
<br />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 CONTRACTOR 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 />LTR
<br />TYPE OF INSURANCE
<br />ADDL
<br />INSR
<br />WVD
<br />POLICY NUMBER
<br />(MM/DD/YYYY)
<br />(POLICY
<br />M DD/VYEVYY)
<br />LIMITS
<br />A
<br />X
<br />COMMERCIAL GENERAL LIABILITY
<br />X
<br />X
<br />6081320801
<br />07/09/2021
<br />07/09/2022
<br />EACH OCCURRENCE
<br />$1,000,000
<br />$100,000
<br />$15,000
<br />CLAIMS -MADE
<br />X
<br />OCCUR
<br />PRE
<br />MISES
<br />(Ea 000wrrence)
<br />MED EXP (Any one person)
<br />X
<br />PD Ded:25,000
<br />PERSONAL & ADV INJURY
<br />$1,000,000
<br />$2,000/000
<br />$2,000,000
<br />GEN'L
<br />AGGREGATE LIMIT APPLIES PER:
<br />GENERAL AGGREGATE
<br />PRODUCTS - COMP/OP AGG
<br />POLICY
<br />A
<br />JECT
<br />LOC
<br />$
<br />OTHER:
<br />E
<br />AUTOMOBILE
<br />LIABILITY
<br />X
<br />X
<br />6081320815
<br />07/09/2022
<br />(Ea aocidoDtSINGLE LIMIT
<br />$1,000,000
<br />07/09/2021
<br />BODILY INJURY (Per person)
<br />$
<br />X
<br />ANY AUTO
<br />BODILY INJURY (Per accident)
<br />$
<br />OWNED
<br />AUTOS ONLY
<br />SCHEDULED
<br />AUTOS
<br />PROPERTY DAMAGE
<br />_
<br />X
<br />AUTOS
<br />ONLY
<br />_
<br />X
<br />NON -OWNED
<br />ONLY
<br />(Per accident)
<br />$
<br />_AUTOS
<br />B
<br />x
<br />UMBRELLALIAB
<br />X
<br />OCCUR
<br />CUP1S95288521NF
<br />07/09/2022
<br />EACH OCCURRENCE
<br />$10,000,000
<br />$10,000,000
<br />$
<br />07/09/2021
<br />AGGREGATE
<br />EXCESS LIAR
<br />CLAIMS -MADE
<br />DED
<br />RETENT ON$
<br />A
<br />WORKERS
<br />AND
<br />EMPLOYERS'
<br />COMPENSATION
<br />LIABILITY Y/N
<br />WA Stop Gap
<br />07/09/2022
<br />STATUTE
<br />FOR"
<br />07/09/2021
<br />E.L. EACH ACCIDENT
<br />$1,000,000
<br />$1,000,000
<br />ANY
<br />OFFICER/MEMBER
<br />PROPRIETOR/PARTNER/EXECUTIVE
<br />EXCLUDED?
<br />N
<br />N / A
<br />6081320801
<br />E.L. DISEASE - EA EMPLOYEE
<br />(Mandatory
<br />If yes,
<br />DESCRIPTION
<br />Dye
<br />in NH)
<br />undere OF OPERATIONS below
<br />E.L. DISEASE - POLICY LIMIT
<br />$1,0001000
<br />C
<br />D
<br />XS
<br />Umbrella
<br />Pollution/Prof
<br />over
<br />Lead
<br />$10
<br />ECO2261611766
<br />COOG23897854013
<br />07/09/2021
<br />07/09/2020
<br />07/09/2022
<br />07/09/2022
<br />15,000,000 OCC
<br />15,000,000 AGG
<br />3,000,000 OCC/AGG
<br />DESCRIPTION
<br />Re:
<br />City
<br />Additional
<br />Job
<br />of
<br />Everett,
<br />OF OPERATIONS
<br />Order Contracting
<br />its
<br />Insured
<br />/ LOCATIONS/VEHICLES
<br />for the City
<br />officers, employees
<br />Status applies per
<br />(ACORD
<br />of
<br />and
<br />attached
<br />1011 Additional Remarks Schedule, may be attached If more space Is req fired)
<br />Everett - Year 1.
<br />agents.
<br />form(s).
<br />CERTIFICATE HOLDER
<br />CANCELLATION
<br />City of Everett
<br />3200 Cedar Street
<br />Everett, WA 98201
<br />SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
<br />THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
<br />ACCORDANCE WITH THE POLICY PROVISIONS.
<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 />#54761403/M4695242 KTROO
<br />
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