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.4`ORO <br />BURTCON-04 <br />CERTIFICATE OF LIABILITY INSURANCE <br />KDIEHL <br />DATE (MM/DDIYYYY) <br />9/2/2021 <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(ies) 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 <br />Hub International Northwest LLC <br />PO Box 3144 <br />Spokane, WA 99220 <br />INSURED <br />Burton Construction, Inc. <br />3915 E Nebraska <br />Spokane 99217 <br />oiQ ecT Kris Diehl <br />GA /CN NO, Exq: (509) 319-2908 <br />E-MAILDADDRESS Kris.Diehl©hubinternational.com <br />INSURER(S) AFFORDING COVERAGE <br />(AA(C, No): <br />INSURER A: The Phoenix Insurance Company <br />INSURER B : Charter Oak Fire Insurance Company <br />INSURER C: Travelers Property Casualty Company of America <br />INSURER D : <br />NAIC # <br />25623 <br />25615 <br />25674 <br />INSURER E <br />INSURER F : <br />.....•_I..-......—.-...........-�...__.-. __...._.. <br />THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD <br />THIS IS TO CERTIFY <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 POLIC ES 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 <br />ADDL <br />SUBR <br />POLICY EFF <br />POLICY EXP <br />LIMITS <br />LTR <br />TYPE OF INSURANCE <br />MD <br />WVD <br />POLICY NUMBER <br />IMM/DD/YYYYI <br />(MM/DD(YYYYI <br />A <br />X <br />COMMERCIAL GENERAL LIABILITY <br />EACH OCCURRENCE <br />$ 1,000,000 <br />CLAIMS -MADE <br />X <br />OCCUR <br />X <br />X <br />DTCO5J58662APHX21 <br />7/7/2021 <br />71712022 <br />POREMISES(Eaoccurrr neel <br />$ 300,000 <br />X <br />$2 500 PD Deductible <br />MED EXP (Anyone person) <br />$ 5,000 <br />PERSONAL &ADV INJURY <br />$ 1,000,000 <br />2,000,000 <br />GEN'L AGGREGATE LIMIT APPLIES PER: <br />GENERAL AGGREGATE <br />$ <br />2,000,000 <br />POLICY <br />X <br />5Eq8f <br />X <br />LOC <br />PRODUCTS - COMP/OP AGG <br />$ <br />OTHER: <br />WA STOP GAP <br />$ 1,000,000 <br />B <br />AUTOMOBILE <br />LIABILITY <br />COMBINED SINGLE LIMIT <br />(Fa accldenf <br />1,000,000 <br />$ <br />X <br />ANY AUTO <br />8102N5323762126G <br />7/7/2021 <br />7/7/2022 <br />BODILY INJURY (Per person) <br />$ <br />OWNED <br />DONLY <br />AUTOS <br />AUTOSULED <br />BODILY INJURY (PeraWdenp <br />$ <br />_ <br />X <br />AUTOS <br />X <br />ANUTOSONLV <br />OMB <br />PAdaRt�1AMAGE <br />ONLY <br />$ <br />C <br />X <br />UMBRELLALIAB <br />X <br />OCCUR <br />EACH OCCURRENCE <br />$ 5,000,000 <br />EXCESSLIAB <br />CLAIMS -MADE <br />CUP9H8825192126 <br />717/2021 <br />7/7/2022 <br />AGGREGATE <br />$ 5,000,000 <br />DED <br />X <br />RETENT ON 10,000 <br />$ <br />WORKERS <br />COMPENSATION <br />PERTUTE <br />I <br />FERROTH <br />AND EMPLOYERS' LIABILITY YIN <br />ANYANPRRO(PREETgORR/PARTNER/EXECUTIVE <br />E.L. EACH ACCIDENT <br />$ <br />EXCLUDED?E.L. <br />1 <br />N(A <br />(Mandatory In NH) <br />DISEASE - EA EMPLOYEE, <br />$ <br />If yes, describe under <br />DESCRIPTION OF OPERATIONS below <br />E.L. DISEASE - POLICY LIMIT <br />$ <br />DESCRIPTION <br />AS RESPECTS <br />OF OPERATIONS / LOCATIONS <br />CITY OF EVERETT <br />STATUS <br />/ VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space Is requl ed) <br />JOC, CONTRACT #2021-022 <br />INCLUDING WAIVER OF SUBROGATION IS GRANTED AS IT RELATES TO GENERAL LIABILITY IN ACCORDANCE WITH <br />ADDITIONAL INSURED <br />TERMS AND CONDITIONS OF THE POLICY TO CITY OF EVERETT PER THE ACTUAL FORMS ATTACHED TO THIS CERTIFICATE. UMBRELLA FOLLOWS <br />FORM AS IT RELATES TO ADDITIONAL INSUREDS. THE ABOVE COVERAGE IS PRIMARY AND NON-CONTRIBUTORY WHERE REQUIRED BY WRITTEN <br />CONTRACT. <br />CITY OF EVERETT <br />ATTN: THERESA BAUCCIO-TESCHLOG <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 />THIZ <br />©1988.2015 ACORD CORPORATION. All rights reserved. <br />ACORD 25 (2016/03) <br />The ACORD name and logo are registered marks of ACORD <br />