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oRo® CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY)
<br /> 6/23/2017
<br /> CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS
<br /> TIFICATE 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 /> CONT
<br /> PRODUCER NAMEACT Stephen Erni
<br /> Arthur J. Gallagher Risk Management Services, Inc. PHONE 425-454-3386 FAX 425-451-3716
<br /> 777 108th Ave NE,#200 (A/c,Nn-Fzt)• IA/C.Nol:
<br /> Bellevue WA 98004 E-MAIL
<br /> DRESS:Stephen_Erni@ajg.com
<br /> INSURER(S)AFFORDING COVERAGE NAIC#
<br /> INSURERA:Underwriters at Lloyd's London 15792
<br /> INSURED CORPOFT-01 INSURERB:Old Republic Union Insurance Company 31143
<br /> Corporation of the Catholic Archbishop of Seattle INSURER C:State National Insurance Company, Inc 12831
<br /> Catholic Community Services of Western Washington
<br /> 1918 Everett Ave INSURER D:
<br /> Everett WA 98201 INSURER E:
<br /> INSURER F:
<br /> COVERAGES CERTIFICATE NUMBER:338885888 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 ADDL SUBR POLICY EFF POLICY EXP
<br /> LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER IMM/DD/YYYY) IMM/DD/YYYYI LIMITS
<br /> A x COMMERCIAL GENERAL LIABILITY Y BP1023017 7/1/2017 7/1/2018 EACH OCCURRENCE $1,000,000
<br /> DAMAGE TO RENTED
<br /> CLAIMS-MADE X OCCUR PREMISES(Ea occurrence) $1,000,000
<br /> MED EXP(Any one person) $Nil
<br /> PERSONAL&ADV INJURY $1,000,000
<br /> GENL AGGREGATE LIMIT APPLIES PER GENERAL AGGREGATE $1,000,000
<br /> X POLICY PRO-
<br /> JECT LOC PRODUCTS-COMP/OPAGG $1,000,000
<br /> OTHER: $
<br /> A AUTOMOBILE LIABILITY BP1023017 7/1/2017 7/1/2018 COMBINED SINGLE LIMIT $
<br /> (Ea accident) 1,000,000
<br /> X ANY AUTO BODILY INJURY(Per person) $
<br /> OWNED SCHEDULED BODILY INJURY(Per accident) $
<br /> AUTOS ONLY AUTOS
<br /> HIRED — NON-OWNED PROPERTY DAMAGE $
<br /> X AUTOS ONLY X AUTOS ONLY (Per accident)
<br /> B UMBRELLA LIAB X OCCUR 821600 0785428 7/1/2017 7/1/2018 EACH OCCURRENCE $5,000,000
<br /> X EXCESS LIAB CLAIMS-MADE AGGREGATE $5,000,000
<br /> DED RETENTION$ $
<br /> A WORKERS COMPENSATION BP1023017 7/1/2017 7/1/2018 XOOTH
<br /> STATUTE
<br /> C AND EMPLOYERS'LIABILITY Y/N NDE-0864512-17 7/1/2017 7/1/2018
<br /> ANY PROPRIETOR/PARTNER/EXECUTIVE NIA E.L.EACH ACCIDENT $1,000,000
<br /> OFFICER/MEMBER EXCLUDED?
<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 /> DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required)
<br /> Limits shown are inclusive of defense and insured retention.
<br /> Certificate Holder is included as Additional Assured as required by contract or agreement per attached endorsement on the policy. Coverage
<br /> only extends for claims arising out of Catholic Community Services fulfillment of their obligations as outlined in the Community Development
<br /> Block Grant Agreement with the City of Everett, for the term of the certificate.
<br /> CERTIFICATE HOLDER CANCELLATION
<br /> SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
<br /> City of Everett,its officers,employees and agents THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
<br /> 2930 Wetmore Ave. ACCORDANCE WITH THE POLICY PROVISIONS.
<br /> Everett WA 98201
<br /> USA
<br /> AUTHORIZED REPRESENTATIVE
<br /> d,„,,,,4,.4.....,
<br /> ©1988-2015 ACORD CORPORATION. All rights reserved.
<br /> ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD
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