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PROPEL INSURANCE PAGE 3 OF 16
<br /> Client#: 129019 FORMCONS
<br /> E(MMA
<br /> ACORD, DAT
<br /> CERTIFICATE OF LIABILITY INSURANCE
<br /> 7/E(MMIDDNYYY)
<br /> 7
<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(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 NpMEACT Michelle Savage
<br /> Propel Insurance PHONE 800 499-0933 FAX 866 577-1326
<br /> (A/C,No,Ext): (A/C,No):
<br /> Tacoma Commercial Insurance E-MAIL michelle.sava e elinsurance.com
<br /> ADDRESS: g �Pro P
<br /> 1201 Pacific Ave,Suite 1000 INSURER(S)AFFORDINGCOVERAGE NAIC#
<br /> Tacoma,WA 98402 INSURER A:Zurich-American Insurance Com pa 16535
<br /> INSURED INSURER B:American Guarantee and Liabilit 26247
<br /> Forma Construction Company
<br /> INSURER C:Illinois Union Insurance Com pan 27960
<br /> PO Box 11489 7 •
<br /> INSURER D: 7
<br /> y Travelers PropertyCasualty Co 25674
<br /> Olympia,WA 98508
<br /> INSURER E:
<br /> INSURER F:
<br /> COVERAGES CERTIFICATE NUMBER: 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 TYPE OF INSURANCE ADDLSUBR POLICY EFF POLICY EXP LIMITS
<br /> LTRINSR WVD POLICY NUMBER (MMIDD/YYYY) (MMIDD/YYYY)
<br /> A X COMMERCIAL GENERAL LIABILITY X X GLA019886301 07/09/2017 07/09/2018 EACH OCCURRENCE $1,000,000
<br /> D
<br /> CLAIMS-MADE XI OCCUR PREMISES(Eaoccurrrence) $300,000
<br /> MED EXP(Any one person) $5,000
<br /> PERSONAL&ADV INJURY $1,000,000 _
<br /> GEN'L AGGREGATE LIMIT APPLIES PER GENERAL AGGREGATE $2,000,000
<br /> 7 POLICY I XI.ECOT 1 LOC PRODUCTS-COMP/OPAGG $2,000,000
<br /> OTHER
<br /> A AUTOMOBILE LIABILITY X GLA019886301 07109/2017 07/09/2018{Ea aBGdeDtSINGLE LIMIT ,000,000
<br /> X ANY AUTO BODILY INJURY(Per person) $
<br /> ALL()MED SCHEDULED BODILY INJURY(Per accident) $
<br /> AUTOS _AUTOS
<br /> X HIRED AUTOS X AUTOS dJED PROPERTY DAMAGE
<br /> _AUTOS (Per accident)
<br /> $
<br /> B X UMBRELLA LIAB X OCCUR X AUC019888101 07/09/2017 07/09/2018 EACH OCCURRENCE $13,000,000
<br /> EXCESS LIAB CLAIMS-MADE AGGREGATE $13,000,000
<br /> DED RETENTION$ $
<br /> A WORKERS COMPENSATION GLA019886301 07/09/2017 07/09/2018 X STATUTE 0TH
<br /> AND EMPLOYERS'LIABILITY
<br /> ANY PROPRIETOR/PARTNER/EXECUTIVE Y IN WA Stop Gap E .EACH ACCIDENT $1,000,000
<br /> OFF ICER/MEMBER EXCLUDED'? NIA
<br /> (Mandatory in NH) E .DISEASE-EA EMPLOYEE $1,000,000
<br /> If yes,describe under
<br /> DESCRIPTION OF OPERATIONS below EL DISEASE-POLICY LIMIT $1,000,000
<br /> C Poll/Prof. L COOG23897854011 07/09/2017 07/09/2018 $3,000,000 OcclAgg
<br /> D Install Floater QT6603H548021TIL 07/09/2017 07/09/2018 $350,000 Limit/$5k Ded
<br /> Per Work Order
<br /> DESCRIPTION OF OPERATIONS!LOCATIONS!VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space is required)
<br /> Re: Job Order Contracting for the City of Everett-year 3. The City of Everett,its officers,employees
<br /> and agents are included as additional insureds per the attached endorsements.
<br /> CERTIFICATE HOLDER CANCELLATION
<br /> Cil of Everett SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
<br /> THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
<br /> 3200 Cedar Street ACCORDANCE WITH THE POLICY PROVISIONS.
<br /> Everett,WA 98201
<br /> AUTHORIZED REPRESENTATIVE
<br /> �� .a.....i c l Z.`�P�11n..1 •r•1S
<br /> ©1988-2014 ACORD CORPORATION.All rights reserved.
<br /> ACORD 25(2014/01) 1 of 1 The ACORD name and logo are registered marks of ACORD
<br /> #S2771371/M2770980 JMR00
<br />
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