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Client#: 129019 FORMCONS
<br /> ACORDTM CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY)
<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(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 any rights to the certificate holder in lieu of such endorsement(s).
<br /> PRODUCER CONTACT Shatanna Hagen
<br /> Propel Insurance HOO,Nt o,Ext):800 499-0933 FAX
<br /> Tacoma Commercial Insurance E-MAIL (A/C,No): 866 577-1326
<br /> ADDRESS: shatanna.hagen@propelinsurance.com
<br /> 1201 Pacific Ave,Suite 1000
<br /> Tacoma,WA 98402 INSURER(S)AFFORDING COVERAGE NAIC#
<br /> INSURER A:National Fire Ins Co of Hartford 20478
<br /> INSURED INSURER B:Travelers Property Casualty CoofAmerica 25674
<br /> Forma Construction Company The Ohio CasualtyInsurance Company24074
<br /> 500 Columbia St NW,Suite 201 INSURERC:
<br /> INSURER D:Illinois Union Insurance Company 27960
<br /> Olympia,WA 98501 ValleyForge Insurance Company20508
<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 /> LT RR ADDL TYPE OF INSURANCE INSR WVDR POLICY NUMBER POLICY EFF POLICY EXP LIMITS
<br /> (MM/DD/YYYY) (MM/DD/YYYY)
<br /> A X COMMERCIAL GENERAL LIABILITY X X 6081320801 07/09/2021 07/09/2022 EACH OCCURRENCE $1,000,000
<br /> D
<br /> CLAIMS-MADE X OCCUR PREMISESO(Ea occurrence) $100,000
<br /> X PD Ded:25,000 MED EXP(Any one person) $15,000
<br /> PERSONAL&ADV INJURY $1,000,000
<br /> GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $2,000,000
<br /> v PRO-
<br /> POLICY X JECT LOC PRODUCTS-COMP/OP AGG $2,000,000 _
<br /> OTHER: _ $
<br /> E AUTOMOBILE LIABILITY X X 6081320815 07/09/2021 07/09/2022 COMaaccidBINEDent)SINGLE LIMIT $1,000,000
<br /> (E
<br /> X ANY AUTO BODILY INJURY(Per person) $
<br /> — OWNED SCHEDULED BODILY INJURY(Per accident) $
<br /> AUTOS ONLY AUTOS
<br /> HIRED NON- WNED PROPERTY DAMAGE
<br /> X AUTOS ONLY X AUTOS ONLY (Per accident) $
<br /> B X UMBRELLA LIAB X OCCUR CUP1 S95288521 NF 07/09/2021 07/09/2022 EACH OCCURRENCE $10,000,000
<br /> EXCESS LIAB CLAIMS-MADE AGGREGATE $10,000,000
<br /> DED RETENTION$ $ _
<br /> A WORKERS COMPENSATION WA Stop Gap 07/09/2021 07/09/2022 STATUTE EOTH
<br /> AND EMPLOYERS'LIABILITY
<br /> ANY PROPRIETOR/PARTNER/EXECUTIVE Y/N 6081320801 E.L.EACH ACCIDENT $1,000,000
<br /> OFFICER/MEMBER EXCLUDED? N N/A
<br /> (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $1,000,000
<br /> If yes,describe under
<br /> DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $1,000,000
<br /> C XS over Lead$10 ECO2261611766 07/09/2021 07/09/2022 15,000,000 OCC
<br /> Umbrella 15,000,000 AGG
<br /> D Pollution/Prof COOG23897854013 67/09/2020 07/09/2022 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 1.
<br /> City of Everett, its officers,employees and agents.
<br /> Additional Insured Status applies per attached form(s).
<br /> CERTIFICATE HOLDER CANCELLATION
<br /> Cityof Everett SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
<br /> 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 /> A.
<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 /> #S4761403/M4695242 KTROO
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