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AC E) CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY)
<br /> 11/22/2021_
<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 /> CONTACT
<br /> PRODUCER Liberty Mutual Insurance NAME:
<br /> PO Box 188065 PHONE 800-962-7132 FAX
<br /> (A/C,No): 800 845 3666
<br /> E-MAILNo,Ext):
<br /> Fairfield, OH 45018 E-M
<br /> ADDRESS: BusinessService@LibertyMutual.com
<br /> INSURER(S)AFFORDING COVERAGE NAIC#
<br /> INSURER A: Ohio Security Insurance Company 24082
<br /> INSURED
<br /> INSURER B
<br /> Liquid Provisions, LLC
<br /> DBA The Grape And Grain INSURER C:
<br /> 6502 Evergreen Way INSURER D:
<br /> Everett WA 98203 INSURER E:
<br /> INSURER F:
<br /> COVERAGES CERTIFICATE NUMBER: 65123147 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 /> IN SR R ADDL TYPE OF INSURANCE INSD SUBR WVD POLICY NUMBER POLICY EFF POLICY EXP LIMITS
<br /> (MM/DD/YYYY) (MM/DD/YYYY)
<br /> A / COMMERCIAL GENERAL LIABILITY ✓ BKS62354013 12/14/2020 12/14/2021 EACH OCCURRENCE $1,000,000
<br /> DAMAGE RETED
<br /> CLAIMS-MADE ✓ OCCUR PREMISESO(Ea occurrence) $1,000,000
<br /> 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 /> ✓ POLICY PRO-
<br /> 1 LOC PRODUCTS-COMP/OPAGG $2,000,000
<br /> OTHER: $
<br /> A AUTOMOBILE LIABILITY BAS62354013 11/16/2021 12/14/2021 o aoadeDt)INGLE LIMIT $1,000,000
<br /> ANY AUTO BODILY INJURY(Per person) $
<br /> OWNED SCHEDULED BODILY INJURY(Per accident) $
<br /> AUTOS ONLY AUTOS
<br /> HIRED NON-OWNED PROPERTY DAMAGE $
<br /> ✓ AUTOS ONLY ✓ AUTOS ONLY (Per accident)
<br /> UMBRELLA LIAB OCCUR EACH OCCURRENCE $
<br /> EXCESS LIAB CLAIMS-MADE AGGREGATE $
<br /> DED RETENTION$ $
<br /> A WORKERS COMPENSATION BKS62354013 12/14/2020 12/14/2021 PER OTH PEATUTE ER
<br /> AND EMPLOYERS'LIABILITY Y/N
<br /> ANYPROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $1,000,000
<br /> OFFICER/MEMBEREXCLUDED? N/A
<br /> (Mandatory in NH) Sto Ga E.L.DISEASE-EA EMPLOYEE $1,000,000
<br /> If yes,describe under p p
<br /> DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $1,000,000
<br /> DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required)
<br /> City of Everetts officers,officials,employees,and agents are listed as Additional Insured Owners, Lessees or Contractors per form CG2010.
<br /> 30*Day Notice of Cancellation*10 Day Notice of Cancellation for Cancellation for Non-Payment of Premium
<br /> CERTIFICATE HOLDER CANCELLATION
<br /> SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
<br /> City of Everett, Its officers, officials, employee THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
<br /> and agents ACCORDANCE WITH THE POLICY PROVISIONS.
<br /> 2930 Wetmore Ave
<br /> Everett WA 98201
<br /> AUTHORIZED REPRESENTATIVE
<br /> Brittany Cochran
<br /> ©1988-2015 ACORD CORPORATION. All rights reserved.
<br /> ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD
<br /> 65123220 62354013 1 21 22 GL AU WC Brittany Cochran 111/22/2021 7 35:41 PM (EST) I Page 5 of 5
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