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• 3........'^.41 LUTH-09 OP ID:K1
<br /> AMR p DATE(MM/DD/YYYY)
<br /> CERTIFICATE OF LIABILITY INSURANCE 06/30/2016
<br /> THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS
<br /> CERTIFICATE DOES 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 /> PRODUCER CONTACT Kim Wilson
<br /> Brown&Brown of Washington PONE — FAX --
<br /> 2106 Pacific Ave,Ste 501 (NC.No.Ext):253-396-5500 (ac,N,): 253-396-4500
<br /> Tacoma,WA 98401 ADDRE
<br /> Kim Wilson ADDRESS:
<br /> INSURER(S)AFFORDING COVERAGE NAIC S
<br /> INSURER A:Philadelphia Indemnity Ins.Co 18058
<br /> INSURED Lutheran Community Services NW INSURER B:
<br /> Kay Reed
<br /> 4040 S 188th St#300 INSURER C:
<br /> SeaTac,WA 98188 INSURER D:
<br /> INSURER E:
<br /> INSURER F:
<br /> COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: 003
<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 LIMITS
<br /> LTR INSD D POLICY NUMBER (MM/DD/YYYY) (MM/DDIYYYY)
<br /> A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000
<br /> CLAIMS-MADE X OCCUR X PHPK1519361 07/01/2016 07/01/2017 DRMGETOERa ENccTuErcDence) $ 100,000
<br /> A X SexuallPhys Abuse MED EXP(Any one person) $ 5,000
<br /> A X Professional Liab PHPK1519361 PERSONAL&ADV INJURY $ 1,000,000
<br /> GE 'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 3,000,000
<br /> POLICY PRO LOC PRODUCTS-COMP/OP AGG $ 3,000,000
<br /> PRO-
<br /> JECT _
<br /> OTHER: Emp Ben. $ 1,000,000
<br /> AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ 1,000,000
<br /> (Ea accident)
<br /> A X ANY AUTO PHPK1519361 07/01/2016 07/01/2017 BODILY INJURY(Per person) $
<br /> ALL OWNED SCHEDULED BODILY INJURY(Per accident) $
<br /> AUTOS
<br /> X HIREDISAUTOS X NON SWNED (PPROPERT er accident)
<br /> DAMAGE $
<br /> $
<br /> UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 5,000,000
<br /> A X EXCESS LIAB CLAIMS-MADE PHUB547828 07/01/2016 07/01/2017 AGGREGATE $ 5,000,000
<br /> DED X RETENTION$ 10,000 $
<br /> WORKERS COMPENSATION I STATUTE I X I&H-
<br /> PER
<br /> AND EMPLOYERS'LIABILITY
<br /> A ANY PROPRIETOR/PARTNER/EXECUTIVE YIN PHPK1519361 06/01/2016 06/01/2017 E.L.EACH ACCIDENT $ 1,000,000
<br /> OFFICER/MEMBER EXCLUDED? N/A
<br /> (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 1,000,000
<br /> If yes,describe under
<br /> DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 1,000,000
<br /> A Crime PHSD1159654 07/01/2016 07/01/2017 Crime 500,000
<br /> Employee Theft Deduct 5,000
<br /> DESCRIPTION OF OPERATIONS I LOCATIONS I VE! :,may be attached if more space is required)
<br /> See attached holder notes... Q- ,,r ;o 11,6&#�
<br /> giy,de J 7, kr
<br /> CERTIFICATE HOLDER ` 'a i CANCELLATION
<br /> -
<br /> SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
<br /> Cityof Everett THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
<br /> ACCORDANCE WITH THE POLICY PROVISIONS.
<br /> Dept. of Planning &Comm Devel
<br /> 2930 Wetmore Avenue#9F AUTHORIZED REPRESENTATIVE
<br /> Everett,WA 98201
<br /> ©1988-2014 ACORD CORPORATION. All rights reserved.
<br /> ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD
<br />
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