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ACCPRE)® CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DDYYYY) <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 /> PRODUCER CONTACT Customer Service <br /> NAME: <br /> Jason Johns Agency, LLC PH N o.EXtl: 360-651-7707 FAX No): 360-925-6921 <br /> 514 State Ave,Ste 203 E-MAIL <br /> ADDRESS: <br /> Marysville,WA 98270 INSURER(S)AFFORDING COVERAGE NAIL# <br /> INSURER A: American National 28401 <br /> INSURED INSURER B: <br /> Rucker Avenue Chiropractic Center INSURER C: <br /> 3231 Rucker Ave INSURER D: <br /> Everett,WA 98201-4224 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 /> IPOLICY EFF POLICY EXP <br /> NSR ADDTYPE OF INSURANCE INSD WVDSUBR POLICY NUMBER (MM/DD/YYYY) (MM/DD/YYYY) LIMITS <br /> LTR INSD WVD <br /> COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 2,000,000 <br /> DAMAGE TO RENTED <br /> CLAIMS-MADE OCCUR PREMISES(Ea occurrence) $ <br /> X Business Owner Policy MED EXP(Any one person) $ <br /> A Y 4601X0136 4/15/2021 4/15/2022 PERSONAL&ADV INJURY $ <br /> GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 4,000,000 <br /> POLICY PRO- <br /> JECT LOC PRODUCTS-COMP/OP AGG $ <br /> OTHER: $ <br /> AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ <br /> (Ea accident) <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 /> WORKERS COMPENSATION PER OTH- <br /> AND EMPLOYERS'LIABILITY Y/N STATUTE ER <br /> ANYPROPRIETOR/PARTNER/EXECUTIVE N/A E.L.EACH ACCIDENT $ <br /> OFFICER/MEMBEREXCLUDED? <br /> (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ <br /> If yes,describe under <br /> DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ <br /> DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) <br /> CERTIFICATE HOLDER CANCELLATION <br /> SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE <br /> THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN <br /> CITY OF EVERETT ACCORDANCE WITH THE POLICY PROVISIONS. <br /> 2930 WETMORE AVE STE A <br /> AUTHORIZED REPRESENTATIVE <br /> EVERETT WA,98201-4067 9(1414$199M.. <br /> ©1988-2015 ACORD CORPORATION. All rights reserved. <br /> ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD <br />