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DATE(MM/DDNYYY) <br /> ACORN® CERTIFICATE OF LIABILITY INSURANCE <br /> L—/ 09/30/2016 <br /> THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS <br /> CERTIFICATE DOES NOTAFFIRMATIVELY 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 /> PRODUCER CON iACI <br /> NAME: <br /> PHONE FAX <br /> Leavitt Group Northwest (A/C No,Ext): (A/C,No): <br /> PO Box 9068 ADDRESS: <br /> INSURER(S)AFFORDING COVERAGE NAIC# <br /> Tacoma WA 98490 INSURERA: Scottsdale Insurance Co. 41297 <br /> INSURED INSURER B: <br /> Third Hand Cloud Tai Chi Co INSURER C: <br /> 417 Tamarack INSURERD: <br /> INSURER E: <br /> Everett WA 98203 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 AUULSUBK POLICY EFF POLICY EXP <br /> LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER (MM/DDNYYY) (MM/DDNYYY) LIMITS <br /> X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCEDAMAGE T $ 1,000,000 <br /> RENTED <br /> CLAIMS-MADE 7 OCCUR PREM SESO(Ea occurrence) $ 100,000 _ <br /> MED EXP(Any one person) $ 1,000 <br /> A CPS2469544 05/09/2016 05/09/2017 PERSONAL&ADV INJURY $ 1,000,000 <br /> GENII_AGGREGATE LIMITAPPLIES PER. GENERAL AGGREGATE $ 2,000,000 <br /> X POLICYn Fm <br /> n LOC <br /> 7 PRODUCTS-COMP/OPAGG $ Included _ <br /> OTHER: $ <br /> AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ <br /> (Ea accident) <br /> — <br /> ANY AUTO BODILY INJURY(Per person) $ <br /> ALL OWNED SCHEDULED BODILY INJURY(Per accident) $ <br /> AUTOS _ AUTOS _ <br /> HIR HUAUIOS NON-OWNED PROPERTY DAMAGE $ <br /> AUTOS (Per accident) <br /> UMBRELLA LIAB OCCUR EACH OCCURRENCE _ $ <br /> EXCESS LIAB CLAIMS-MADE AGGREGATE $ <br /> DED I RETENTION$ $ <br /> WORKERS COMPENSATION I PER <br /> ER I (NI <br /> AND EMPLOYERS'LIABILITY Y/N <br /> ANY PROPRIETOR/PARTNER/EXECUTIVE LIN!A E .EACH ACCIDENT $ <br /> OFFICER/MEMBER EXCLUDED? <br /> (Mandatory in NH) E .DISEASE-EA EMPLOYEE $ <br /> If yes,describe under <br /> DESCRIPTION OF OPERATIONS below E .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 is named additional insured per form CG2026(04/13). <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 /> Its Officers, Employees and Agents <br /> AUTHORIZED REPRESENTATIVE <br /> 802 E Mukilteo Blvd <br /> Everett WA 98203 deo <br /> I <br /> ©1988-2014 ACORD CORPORATION. All rights reserved. <br /> ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD <br />