Community Health Center of Snohomish County 2/22/2017

ACC �® DATE(M7/ 7YY) A (_VR CERTIFICATE OF LIABILITY INSURANCE 03/17/2017 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND l'HE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT NAME: Parker,Smith&Feek,Inc. PHONE 425-709-3600 FAX 425-709-7460 2233 112th Avenue NE E MAIC° Ext): (A/c,No): Bellevue,WA 98004 ADDRESS: INSURER(S)AFFORDING COVERAGE NAIC# INSURER A: Physicians Insurance A Mutual Company INSURED INSURER B: Community Health Center of Snohomish Co 8609 Evergreen Way INSURER C: Everett,WA 98208 INSURER D: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCE ADDL SUBR POLICY EFF POLICY EXPDILIMITS LTR INSR WYD POLICY NUMBER (MM/DYYYY) (MM/DD/YYYY) A GENERAL LIABILITY 300002865 6/1/2016 6/1/2017 EACH OCCURRENCE $ 1,000,000 DAMAGE TO RENTED 1,000,000 X COMMERCIAL GENERAL LIABILITY X PREMISES(Ea occurrence) $ X CLAIMS-MADE OCCUR MED EXP(Any one person) $ 25,000 PERSONAL&ADV INJURY $ Included _ X Retro Date:06/01/2016 GENERAL AGGREGATE $ 5,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ Included POLICY PRO- JECT AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT (Ea accident) ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS _ AUTOS NON-OWNED PROPERTY DAMAGE $ HIRED AUTOS AUTOS (Per accident) UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ A WORKERS COMPENSATION 300002865 X ORS LIT TS T AND EMPLOYERS'LIABILITYY/N 6/1/2016 6/1/2017 1 r00o'o00 ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? N/A (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $ 1,000,0(10 If yes,describe under 1,000,000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ A Claims-Made/Retro Date:1/1/2004 300002865 6/1/2016 6/1/2017 $1,000,000 Per Claim $5,000,000 Aggregate DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (Attach ACORD 101,Additional Remarks Schedule,If more space is required) The City of Everett,its officers,employees and agents solely vitEpCVT-lyrr}�q ds Grant contract are included as additional insured on the General Liability policy per the attached endorsement/form. �t ��// �� MAR 2 1 2017 CITY OF EVERETT PLANNING DEPT CERTIFICATE HOLDER CANCELLATION City of Everett SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Department of Planning and Community THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Development ACCORDANCE WITH THE POLICY PROVISIONS. Attn:Rebecca McCray 2930 Wetmore Avenue,Suite 8A AUTHORIZED REPRESENTATIVE Everett,WA 98201-4044 ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD 1 of 3 COMMHECE(DLD00)