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1 ® DATE(MMIDD/YYYY)
<br /> AC o CERTIFICATE OF LIABILITY INSURANCE
<br /> 05/10/2016
<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 be endorsed. If SUBROGATION IS WAIVED,subject to
<br /> the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the
<br /> certificate holder in lieu of such endorsement(s).
<br /> CONTACT Sandra Koker
<br /> PRODUCER NAME:
<br /> PHONEFAX 332-7293
<br /> Fortiphi Insurance LLC (AIC.No.E#): (360)332-7300 (AIC.Nor. (360)332-7293
<br /> 288 Martin St,Suite 201 ADDRESS: sandra.koker@fortiphi.com
<br /> Blaine,WA 98230 INSURER(S)AFFORDING COVERAGE NAIC#
<br /> INSURERA: CNA 20478
<br /> INSURED INSURER B: Mutual of Enumclaw 14761
<br /> Materials Testing and Consulting Inc INSURER C: CNA 20443
<br /> 805 Dupont Street Suite 5 INSURER D: Admiral Insurance Company
<br /> Bellingham,WA 98225 INSURERE:
<br /> INSURER F:
<br /> COVERAGES CERTIFICATE NUMBER: 00000000-0 REVISION NUMBER: 40
<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 /> ADDLI SUER POLICY EFF POLICY EXP
<br /> INSR
<br /> TR TYPE OF INSURANCE INSD 1 WVD POLICY NUMBER (MMIDD/YYYY) (MM/DDIYYYY) LIMITS
<br /> A X COMMERCIAL GENERAL LIABILITY Y Y 6012230098 07/01/2015 07/01/2016 EACH OCCURRENCE $ 1,000,000
<br /> DAMAGE TO CLAIMS-MADE X OCCUR PREMISES(Ea occurrence) $ 300,000
<br /> MED EXP(Any one person) $ 10,000
<br /> PERSONAL&ADV INJURY $ 1,000,000
<br /> GE 'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000
<br /> PRaT I_ I LOC PRODUCTS-COMP/OP AGG $ _ JOOO,OOO
<br /> POLICY I X JEC _. - "-
<br /> OTHER: $
<br /> AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT
<br /> B Y BAP0004540 07/01/2015 ' 07/01/2016 (Ea accident) $ 1,000,000
<br /> X ANY AUTO BODILY INJURY(Per person) $
<br /> ALL OWNED SCHEDULED BODILY INJURY(Per accident) $
<br /> AUTOS _ AUTOS
<br /> NON-OWNED PROPERTY DAMAGE $
<br /> HIRED AUTOS AUTOS (Per accident)
<br /> $
<br /> C X UMBRELLA LIAB _ OCCUR 6012230117 07/01/2015 07/01/2016 EACH OCCURRENCE $ 2,000,000
<br /> EXCESS LIAB X CLAIMS-MADE AGGREGATE $ 2,000,000
<br /> DED X RETENTION$ 10,000 $
<br /> A WORKERS
<br /> CAND EMPLOYERS' 6012230098 07/01/2015 07/01/2016 I STATUTE X EH-
<br /> Stop Gap
<br /> YIN E.L.EACH ACCIDENT $ 1,000,000
<br /> ANYOFFICPROPRIETOR/PARTNER/EXECUTIVE R/PXCLUDEDXECUTIVE Y N I A
<br /> (Mandatory in NH)ER EXCLUDED? _E.L.DISEASE-EA EMPLOYEE $ 1,000,000
<br /> (Mandatory
<br /> If yes,describe and under
<br /> DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 1,000,000
<br /> B Excess Auto UMC0004181 07/01/2015 07/01/2016 2,000,000
<br /> D Professional Liab E0000029495-01 07/01/2015 07/01/2016 Each Claim 2,000,000
<br /> DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space is required)
<br /> City of Everett,and its officers,employees and agents are Additional Insureds as respects to work performed on their behalf
<br /> by the Named Insured.Blanket additional insured endorsement SB-146932-E applies.Coverage is primary and
<br /> non-contributory. Per project aggregate is included. Waiver of subrogration included. 30 day cancellation notice applies.
<br /> Project: 41st STREET TO WEST MARING VIEW DRIVE FREIGHT CORRIDOR IMPROVEMENTS,Job:COE W.O.#PW-347
<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 /> 3101 Cedar Street
<br /> Everett,WA 98201 AUTHORIZED REPRESENTATIVE
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<br /> ©1988-2014 ACORD CORPORATION. All rights reserved.
<br /> ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD
<br /> Printed by SDK on May 10,2016 at 02:57PM
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