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DATE(MM/DD/YY)
<br /> • ACO/2I0
<br /> CERTIFICATE OF LIABILITY INSURANCE 5 09/14/20111
<br /> THIS
<br /> 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(les) 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 LIC #0437153 1-212-948-1306 CONTACT
<br /> NAME:
<br /> Marsh Risk & Insurance Services PHONE FAX
<br /> CIRTS_Support@internal.j acobs.com (AMA No.Ext): (AIC,No):
<br /> 777 S. Figueroa Street ADDRESS:
<br /> PRODUCER
<br /> Los Angeles, CA 90017-5822 CUSTOMER ID#:
<br /> Fax to: 1-212-948-1306 INSURER(S)AFFORDINGCOVERAGE . . .NAIC#
<br /> INSUREDINSURERA: ACE AMER INS CO 22667
<br /> Jacobs Engineering Group Inc. INSURERB:
<br /> 1111 South Arroyo Parkway INSURERC:
<br /> P.O. Box 7084 INSURERD:
<br /> Pasadena, CA 91109-7084
<br /> INSURER E:
<br /> INSURER F:
<br /> COVERAGES CERTIFICATE NUMBER: 23060908 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 ADDL SUBR POLICY EFF POLICY EXP LIMITS
<br /> LIR TYPE OF INSURANCE NSR AND POLICY NUMBER IMIY
<br /> M/DDYYYL(MM/DD/YYYY)
<br /> A GENERALUABIUTY HDO G2552903007/01/11 07/01/12 EACH OCCURRENCE $ 1,000,000
<br /> DAMAGE TO RENTED 250,000
<br /> X COMMERCIAL GENERAL LIABILITY PREMISES(Ea occurrence) $
<br /> CLAIMS-MADE X OCCUR MED EXP(My one person) $ 5,000
<br /> X CONTRACTUAL LIABILITY PERSONAL&ADV INJURY $ 1,000,000
<br /> GENERAL AGGREGATE $ 2,000,000 •
<br /> GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 1,0 0 0,000
<br /> nPOLICY n,ZS P1 LOC • $
<br /> A AUTOMOBILELIABIUTY ISA H08635651 07/01/11 07/01/12 COMBINED SINGLE LIMIT $ 1,000,000
<br /> (Ea accident)
<br /> X ANY AUTO BODILY INJURY(Per person) $
<br /> ALL OWNED AUTOS BODILY INJURY(Per accident) $
<br /> SCHEDULED AUTOS PROPERTY DAMAGE $
<br /> HIRED AUTOS (Per accident)
<br /> NON-OWNED AUTOS $
<br /> $
<br /> UMBRELLA LIAB OCCUR EACH OCCURRENCE $
<br /> EXCESS LIAB CLAIMS-MADE AGGREGATE $
<br /> — DEDUCTIBLE
<br /> RETENTION $ $
<br /> WORKERSCOMPENSATION WCU C46479968 (LA, OH, TX)'07/01/17 07/01/12 XI WCSTATU- °R-
<br /> AND TORY LIMITS ER
<br /> •
<br /> ANYERIP OYERS'UABILITYRIETOPJPARTNERI YIN WLR C46479920 (AOS) 07/01/11 07/01/12 E.L.EACHACCIDENT $ 1,000,000
<br /> A ANY PROPRIETOR/PARTNER/IXECUTNE
<br /> ER EXCLUDED? N NIA
<br /> A (Mandatoryin NH) SCF C4647.9944 (ME, WI) 07/01/11 07/01/12 EL.DISEASE-EAEMPLOYEE $ 1,000,000
<br /> If yes,describe under
<br /> DESCRIPTION OF OPERATIONS below E.L.DISEASE•POLICY LIMIT $ 1,000,000
<br /> A PROFESSIONAL LIABILITY EON 021655065 003 07/01/11 07/01/12 PER CLAIM/PER 1,000,000
<br /> "CLAIMS MADE" AGGREGATE 1,000,000
<br /> DEFENSE INCLUDED •
<br /> DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (Attach ACORD 101,Additional Remarks Schedule,If more space is required)
<br /> OFFICE LOCATION: Bellevue, WA 98004. PROJECT MGR: Dennis Demuth. SENIOR CONTRACT MGR: Glenn R. Young.' RE: Sewer "M"
<br /> Project, UP 3470 - Sewer System Replacement & Capacity Improvements. CONTRACT END DATE: 09/01/2014. SECTOR: Public.
<br /> *$2,000,000 SIR FOR STATES OF: LA, OH, TX. The City of Everett, its officers, employees and agents are added as an
<br /> additional insured for general liability & auto liability as respects the negligence of the insured in the performance
<br /> of insured's services to cert holder under contract for captioned work. Coverage is primary and certificate holder's
<br /> insurance is excess and non-contributory. *THE TERMS, CONDITIONS, AND LIMITS PROVIDED UNDER THIS CERTIFICATE OF
<br /> INSURANCE WILL NOT EXCEED OR BROADEN IN ANY WAY THE TERMS, CONDITIONS, AND LIMITS AGREED TO UNDER THE APPLICABLE
<br /> CERTIFICATE HOLDER CANCELLATION
<br /> SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
<br /> City of Everett • THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
<br /> ACCORDANCE WITH THE POLICY PROVISIONS.
<br /> •
<br /> 3200 Cedar Avenue AUTHORIZED REPRESENTATIVE ``��
<br /> I�
<br /> Everett, WA 98201 ( t..S 4v1.
<br /> USA
<br /> I
<br /> nyumdo_newgalexy • ©1988-2009 ACORD CORPORATION. All rights reserved.
<br /> ACORD 25(2009109) The ACORD name and logo44 registered marks of ACORD
<br /> 23060908
<br />
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