Laserfiche WebLink
COMMERCIAL GENERAL LIABILITY COVERAGE PART DECLARATIONS <br />POLICY NUMBER: NN1285075 <br />Extension of Declarations is attached. <br />Effective Date: 06/19/2021 12:01 A.M. Standard Time <br />LIMITS OF INSURANCE ❑ If box is checked, refer to form S132Amendment of Limits of Insurance. <br />General Aggregate Limit (Other Than Products/Completed <br />Products/Completed Operations Aggregate Limit <br />Personal and Advertising Injury Limit <br />Each Occurrence Limit <br />Damage To Premises Rented To You Limit <br />Medical Expense Limit <br />Operations) $ 2,000,000 <br />Or Organization <br />$ 2,000,000 <br />$ 1,000,000 Any One Person <br />$ 1,000,000 <br />$ 100, 000 Any One Premises <br />$ 5,000 Any one Person <br />RETROACTIVE DATE (CG 00 02 ONLY) <br />This insurance does not apply to "bodily injury", "property damage" or "personal and advertising injury" which occurs <br />before the Retroactive Date, if any, shown here: NONE (Enter Date or "NONE" if no Retroactive Date applies) <br />BUSINESS DESCRIPTION AND LOCATION OF PREMISES <br />BUSINESS DESCRIPTION: FABRICATION OF PUBLIC ART <br />LOCATION OF ALL PREMISES YOU OWN, RENT, OR OCCUPY: <br />1.10321 8TH AVE. NW <br />SEATTLE WA 98177- <br />2. <br />Additional locations (if any) will be shown on form S170, Commercial <br />Extension_ <br />LOCATION OF JOB SITE (If Designated Projects are to be Scheduled): <br />address is same as mailing address. <br />Liability Coverage Part Declarations <br />E Location <br />General <br />CODE # - CLASSIFICATION <br />, <br />PREMIUM <br />BASIS <br />RATE <br />ADVANCE <br />PREMIUM <br />Prem/Ops <br />Prod/Comp <br />Ops <br />97650 - Metal Erection decorative or artistic <br />90792 - First Party Privacy Breach Cov-Low <br />Hazard -Low Exposure <br />-Per Form L411 <br />90747 - Lost Key Coverage <br />-Per Form S185 <br />66010 - Hired and Non -Owned Auto - up to 25 <br />Employees <br />Rate is Total Number of Employees <br />-Per Form L270 <br />p <br />17, 800 <br />IF ANY <br />IF ANY <br />IF ANY <br />28.736 <br />INCLUDED <br />FLAT <br />23.091 <br />512 <br />411 <br />55 <br />INCLUDED <br />238 <br />* PREMIUM BASIS SYMBOLS + = Products/Completed Operations are subject to the General Aggregate Limit <br />a = Area (per 1,000 sq. ff. of area) 0 = Total Operating Expenditures s = Gross Sales (per $1,000 of Gross Sales) <br />c = Total Cost (per $1,000 of Total Cost) (per $1,000 Total Operating Expenditures) t = See Classification <br />m= Admissions (per 1,000 Admissions) p = Payroll (per $1,000 of Payroll) u = Units (per unit) <br />PREMIUM FOR THIS PAGE $ 1,216 <br />FORMS AND ENDORSEMENTS (other than applicable Forms and Endorsements shown elsewhere in the policy) <br />Forms and Endorsements applying to this Coverage Part and made part of this policy at time of issue: <br />Refer to Schedule of Forms and Endorsements <br />THESE DECLARATIONS ARE PART OF THE POLICY DECLARATIONS CONTAINING THE NAME OF THE INSURED AND THE POLICY PERIOD. <br />Includes copyrighted material of Insurance Services Office, Inc. with its permission. <br />S150 (07/09) <br />