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ACORD CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY)
<br /> �..----- 7/9/2017 6/6/2017
<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 have ADDITIONAL INSURED provisions or be endorsed.
<br /> If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on
<br /> this certificate does not confer rights to the certificate holder in lieu of such endorsement(s).
<br /> PRODUCER Lockton Insurance Brokers,LLC CONTACT
<br /> NAME:
<br /> CA Licence#0F15767 PHONE FAX
<br /> (N725 S.Figueroa Street,35th fl. I AIS° Ext): (A/C,No):
<br /> Los Angeles CA 90017 ADDRESS:
<br /> 213-689-0065INSURER(S)AFFORDING COVERAGE NAIC#
<br /> INSURER A:Valley Forge Insurance Company 20508
<br /> INSURED KDW Salas O'Brien,LLC INSURER B:Continental Casualty Company 20443
<br /> 1429881 c/o Salas O'Brien Holdings,Inc. INSURER C:American Casualty Company of Reading,PA 20427
<br /> 3700 South Susan St,Ste 100 INSURER D:
<br /> Santa Ana CA 92704
<br /> INSURER E:
<br /> INSURER F:
<br /> COVERAGES SALOB01 CERTIFICATE NUMBER: 14720546 REVISION NUMBER: XXXXXXX
<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
<br /> S
<br /> LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER POLICY EFF POLICY EXP LIMITS
<br /> (MMMI
<br /> /DD/YYYY) (MDDM(YY)
<br /> A X COMMERCIAL GENERAL LIABILITY N N 6045332482 6/1/2017 6/1/2018 EACH OCCURRENCE $ 2,000,000
<br /> DAMAGE TO CLAIMS-MADE X OCCUR PREMISES EaENTEoccu ence ) $ 1,000,000
<br /> MED EXP(Any one person) $ 10,000
<br /> PERSONAL&ADV INJURY $ 2,000,000
<br /> GE 'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 4,000,000
<br /> POLICY PRO-
<br /> JECT LOC PRODUCTS-COMP/OP AGG $ 4,000,000
<br /> OTHER: $
<br /> B AUTOMOBILE LIABILITY N N 6045332496 6/1/2017 6/1/2018 COMBINED SINGLE LIMIT $
<br /> (Ea accident) 1,000,000
<br /> X ANY AUTO BODILY INJURY(Per person) $ )00(XXXX
<br /> OWNED
<br /> AUTOS ONLY AUTOSULED BODILY INJURY(Per accident) $ XXXXXX
<br /> HIRED NON-OWNED PROPERTY DAMAGE $ )010000l
<br /> AUTOS ONLY AUTOS ONLY (Per accident)
<br /> $ J{1K�K�KXXX
<br /> B x UMBRELLA LIAB X OCCUR N N 6045332501 6/1/2017 6/1/2018 EACH OCCURRENCE $ 5,000,000
<br /> EXCESS LIAB CLAIMS-MADE AGGREGATE $ 5,000,000
<br /> X DED RETENTION$ 10,000 $ XXXXXXX
<br /> A WORKERS COMPENSATION N PER OTH-
<br /> AND EMPLOYERS'LIABILITY WC645903839(CA) 2/18/2017 2/18/2018 X STATUTE ER
<br /> C ANY PROPRIETOR/PARTNER/EXECUTIVE Y/N N/A WC645903842(AOS) 2/18/2017 2/18/2018 E.L.EACH ACCIDENT $ 1,000,000
<br /> OFFICER/MEMBER EXCLUDED? N
<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 /> B Professional Liability N N AEH591877402 7/9/2016 7/9/2017 Each Claim:$5,000,000
<br /> Aggregate:$5,000,000
<br /> DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required)
<br /> THIS CERTIFICATE SUPERSEDES ALL PREVIOUSLY ISSUED CERTIFICATES FOR THIS HOLDER,APPLICABLE TO THE CARRIERS LISTED AND THE POLICY TERM(S)REFERENCED.
<br /> Lift Station Certificate Holder is an Additional Insured to the extent provided by the policy language or endorsement issued or approved by the insurance
<br /> carrier.
<br /> CERTIFICATE HOLDER CANCELLATION
<br /> 14720546
<br /> City of Everett SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
<br /> Lift Stat- THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
<br /> 3200 Cedar Street ACCORDANCE WITH THE POLICY PROVISIONS.
<br /> Everett WA 98201 -
<br /> AUTHORIZED REPR
<br /> ©1 88-201 AC/1a
<br /> ORPORATION. All rights reserved.
<br /> ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD
<br />
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