2017/05/17 Council Agenda Packet

9 A D DATE(MM/DD/YYYY)• CERTIFICATE OF LIABILITY INSURANCE 4111...r'. 5/2/2017 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 THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(les)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). CONTACT . PRODUCER NAME: CL Central Leavitt Group Northwest PHONE Ext): 866-298-0570 Nc,No):866-688-5709 (AIC,No, PO Box 9068 • E-MAIL ADDRESS:cicnorthwest@leavitt.com . INSURER(S)AFFORDING COVERAGE NAIC# Tacoma WA 98490 INSURER A:Ohio Security Insurance Company 024082 INSURED INSURER B:American Fire & Casualty Company 24066 Triangle Associates Inc - INsuRERC:Underwriters at Lloyds of London 15792 811 First Ave #255 INSURER D: INSURER E: Seattle WA 98104 _ INSURERF: COVERAGES CERTIFICATE NUMBER:16/17 Master 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 NSD ISUBR WVD POLICY NUMBER (MM/DDIYYYY) IMMIDLICY EFF D/YYYY)EXP I UMITS LTR 1,000,000 X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ DAMAGE TO RENTED 1,000,000 A CLAIMS-MADE X OCCUR PREMISES(Ea occurrence) $ X Y B&555302282 . 10/23/2016 10/23/2017 MED EXP(Anyone person) $ 15,000 • PERSONAL&ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 3,000,000 • GEN'LAGGREGATE UMITAPPLIES PER: 3,000,000 O PRODUCTS-COMP/OP AGG $ X OLICY jEa LOC Damage to Rental Premises $ 100,000 OTHER: COMBINED SINGLE UMIT $ 1,000,000 AUTOMOBILE LIABILITY (Ea accident) BODILY INJURY(Per person) $ A ANY AUTO _ ALL OWNED SCHEDULED BAS55302282 10/23/2016 10/23/2017 BODILY INJURY(Per accident) $ AUTOS —AUTOS NON-OWNED PROPERTY DAMAGE $ X HIRED AUTOS X AUTOS (Per accident) $ UMBRELLA LIAB _ OCCUR EACH OCCURRENCE $ EXCESS UAB CLAIMS-MADEAGGREGATE $ • I $ DED RETENTION$ I STATUTE I X I a'WORKERS COMPENSATION AND EMPLOYERS'UABIUTY •YIN •WAS Stop Gap E.L EACH ACCIDENT $ 1,000,000 ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? N/A ggA55302282 1D/23/20i6 10/23/2017 EL DISEASE-EA EMPLOYEE $ 1,000,000 B (Mandatory in NN) If yes,describe under EL DISEASE-POLICYUMIT $' 2,000,000 DESCRIPTION OF OPERATIONS below C Professional Liability 52C1033805 7/13/2016 7/13/2017 Per Claim 1,000,000 Deductible 5,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space is required) RE: Everett School Project City of Everett is named additional insured with respects to general liability on primary and non-contributory basis and waiver of subrogration per written contract with the named insured form CG88100413, completed operations form CG85830413. CERTIFICATE HOLDER CANCELLATION ltobin@everettwa.gov • SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE City of Everett THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Public Works Dept 3101 Cedar St AUTHORIZED REPRESENTATIVE Everett, WA 98201 ; D zcTrammell/DITRAM "Z3 • ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo%registered marks of ACORD INS025(201401) U