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• <br /> AC o® CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DO/YYYY) <br /> 03/28/2016 <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 ALYSSA GOLKA <br /> NAME: <br /> StateFarm KATHY NORTHROP PHONE 4253556701 FAX 4253746078 <br /> (A/C.No.Extl: IA/C.No): <br /> 10930 4TH AVE W ADDRESS: ALYSSA©NORTHROPINSURANCE.NET <br /> O'O EVERETT,WA 98204-7006 <br /> INSURER(S)AFFORDING COVERAGE NAIL# <br /> INSURER A: State Farm Fire and Casualty Company 25143 <br /> INSURED <br /> INSURER B <br /> ROXANA L BOROUJERDI DBA FUN TIMES ICE CREAM INSURERC: <br /> 8515 VALHALLA DR INSURERD: <br /> EVERETT,WA 98208 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 /> INSR TYPE OF INSURANCE ADDL SUBR POLICY EFF POLICY EXP UMITS <br /> LTR INSO WVD POUCY NUMBER (MDJYYYYI IMMIQDIYYYYI <br /> COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ <br /> CLAIMS-MADE OCCUR DAMAGE TO RENTED <br /> PREMISES(Ea occurrence) $ <br /> MED EXP(Any one person) $ <br /> PERSONAL 8 ADV INJURY $ <br /> GEN'L AGGREGATE LIMIT APPUES PER: GENERAL AGGREGATE $ _ <br /> POLICY JECTT LOC PRODUCTS-COMP/OP AGG $ <br /> OTHER: $ <br /> AUTOMOBILE UABIUTY 7854359 03/28/2016 09/28/2016 COMBINED SINGLE LIMB $ 2,000,000 <br /> (Ea accident) <br /> ANY AUTO BODILY INJURY(Per person) $ <br /> A /�X/ OWNED - SCHEDULED <br /> AUTOS ONLY AUTOS BODILY INJURY(Per accident) $ <br /> HIRED NON-OWNED PROPERTY DAMAGE <br /> AUTOS ONLY AUTOS ONLY (Per accident) <br /> $ <br /> UMBRELLA UAB OCCUR EACH OCCURRENCE $ <br /> EXCESS UAB CLAIMS-MADE AGGREGATE $ <br /> DED RETENTION$ $ <br /> WORKERS COMPENSATION PER OTH- <br /> AND EMPLOYERS'LIABILITY Y/N STATUTE ER <br /> ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ <br /> OFFICERIMEMBER EXCLUDED? N/A <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 TH:� BOVE DESCRIBE' POLICIES BE CANCELLED BEFORE <br /> THE EXPIRATION 'ATE THEREOF, I*TICE WILL BE DELIVERED IN <br /> CITY OF EVERETT&ITS OFFICERS AND EMPLOYEES AC •RDANCE WI H POLICY PROVI•I•NS. <br /> EVERETT,WA 98208 <br /> A THORIZED R •RESENT TIVE <br /> Ir <br /> ©198 ACORD CORPORATION. All rights reserved. <br /> ACORD 25(2016103) The ACORD name and logo are registered marks o • ORD <br /> 1001486 132849.12 03-16-2016 <br />