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� <br />TRUCKINSURANCE EXCHANGE <br />4880 Wibhiro Boukvard Los Anpeles, Callfomia 90010 <br />INTERIM CERTSFICATE AS TO EVIDENCE OF INSURANCE <br />THIS IS NOT AN IKSURANCE POI.ICY. THIS IS ONLY A V[qIFICATION OF INSURANCE. R DOES NOT IN ANY WAYAMEND, <br />EMEND OR ALTER THE COVERAGE PROVIDED BY THE POLICIES USTED BELOW: <br />N�� • ORLO K WILLIAMS <br />Insured . 4417 CRESENT RD � <br />Address . EVERETT, WA 98203 Agen! ��Y�'�e^Lieb. <br />Pdity Nn. � Auto Liab. <br />Po4.Y No. ' Cargo <br />We certify that policies for the above named insured are in (orce as follovis: <br />PaW.y No. - Work ComP. <br />This Interim Certiticate As to Evidence oi Insurance shall expire sixty days irom M,. <br />_ 3/ 3/ 92 , 19_, unless cancelled prior to such date by written notice to the named insured. <br />COVERED NOT COVERED <br />17I ❑ Premises/Operadons <br />� INCL � Products/Completed OperaHons <br />❑ <br />AUTO UABILIN COVERAGE <br />CQy�RED � N� �VERED <br />u <br />❑ � Hired <br />❑ [?9 Non-Owned <br />❑ L Empiuyer's Non-Ownership <br />BODILY INJURY OR PROPERTY DAMAGE <br />Each Occurronce <br />General Agprepate Lfmit (Other Than Products- <br />Completed Operations) <br />Products Completed Operations Aaqregate <br />Limft <br />Personal 3 Advertisinp Injury <br />Bodily Injury <br />Property Damage <br />i � ��� <br />�� ��� <br />,000 each Person <br />,000 each Accident <br />,000 each Accident <br />_ S _____ __ ,000 each Accident <br />❑ a[ Carpo $ ,000 each Vehicle <br />$ ,000 each Occurrence <br />OINNED ❑ e°��ia°."e0 ❑ .°w"`�"0� <br />AUTOS YEAA, MAKE, TYPE OF BODY, LOAD CAPACITY IDE?I7IFICATION NUMBFA <br />IF RE: MAGENTA APARTPIENTS LAST3 <br />COVERED 5709 HIGHWAY PLACE RIGHT—OF—WAY PERP(IT ;ITS <br />8Y8�8TT, IJh 96ZA� .��JWN <br />WORKERS' COMPENSATION COVERAGE: LIMITS <br />COVEHED NOT COVERED <br />❑ � STATUTORY <br />LIABILITY BODILY INJURY BY <br />INSURANCE BODILY INJURY BY <br />each Accident <br />each Employee <br />Policy Limit <br />UMBRELLA LIABILIN <br />79 03479 28 63 UMBRELLA LIABILIlY 250 ,000 retained limit <br />Poticy Number �, no , nnn 0 each occurrence <br />1,00o,noo agpregate <br />If we cancel this Certificate betore the expiration date we will mail 1 � days wririen notice to the other interest shown below. <br />Certificate issued to: <br />!� N�� , CITY OF EVERETT <br />/� , PUBLIC WORKS <br />Addross . 3200 CEDAR STREET <br />EVERETT, lJA 98201 <br />Countersigned <br />56509'J 151 EDITION i�36 1d0f <br />ALSO NAPIED AS ADD'L INSURED <br />�� 'l�/. •�. � �i � <br />— �,.M�.. <br />/! ,:�'�.�\ <br />��-, _r <br />