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1 ® DATE(MMIDD/YYYY) <br /> A�o CERTIFICATE OF LIABILITY INSURANCE <br /> 05/01/2017 <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 /> CONTACT Jessica Hatley <br /> NAME: y <br /> Vern Fonk Insurance Services Inc ( cc,PHONE.Ext): 206-8594894 FAX <br /> No):206-8594899 <br /> 23830 Pacific Hwy S Ste 104 DRESS: <br /> Kent,WA 98032 INSURER(S)AFFORDING COVERAGE NAIC# <br /> INSURER A: MOUNT VERNON FIRE INSURANCE COMPANY <br /> INSURED INSURER B: <br /> ROXANA L BOROUJERDI <br /> INSURER C: <br /> DBA:FUN TIMES ICE CREAM <br /> INSURER D: <br /> 8515 VALHALLA DR <br /> INSURER E: <br /> EVERETT,WA 98208 <br /> INSURER F: <br /> COVERAGES CERTIFICATE NUMBER: 00000000-26750 REVISION NUMBER: 2 <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 /> IEXP <br /> NSR ADDLTYPE OF INSURANCE INSD wvoSUBR POUCY NUMBER (MM/DD//YYYY) IMM/DDPOUCY EFF Y/YYYY) LIMITS <br /> LIR INSD WVD <br /> A X COMMERCIAL GENERAL LIABILITY y CL2712556 04/28/2017 04/28/2018 EACH OCCURRENCE $ 1,000,000 <br /> DAMAGE RENTED <br /> CLAIMS-MADE X OCCUR PREMSESO(Ea occurrence) $ 100,000 <br /> MED EXP(Any one person) $ 5,000 <br /> PERSONAL&ADV INJURY $ 1,000,000 <br /> GEN'L AGGREGATE UMIT APPUES PER: GENERAL AGGREGATE $ 2,000,000 <br /> X POUCY ,FIEF LOC PRODUCTS-COMP/OP AGG $ INCLUDED <br /> OTHER: • <br /> AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ <br /> (Ea accident) <br /> ANY AUTO BODILY INJURY(Per person) $ <br /> OWNED SCHEDULED BODILY INJURY(Per accident) $ <br /> AUTOS ONLY AUTOS <br /> HIRED NON-OWNED PROPERTY DAMAGE $ <br /> AUTOS ONLY AUTOS ONLY (Per accident) <br /> $ <br /> UMBRELLA LIAB _ OCCUR EACH OCCURRENCE $ <br /> EXCESS UAB CLAIMS-MADE AGGREGATE $ <br /> DED RETENTION$ $ <br /> WORKERS COMPENSATION PER OTH- <br /> AND EMPLOYERS'LIABILITY YIN STATUTE ER <br /> ANY PROPRIETOR/PARTNER/EXECUTIVEN/A E.L.EACH ACCIDENT $ <br /> OFFICER/MEMBER EXCLUDED? <br /> (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ <br /> If yes,describe under <br /> DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ <br /> DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space is required) <br /> Certificate Holder is Additional Insured per Blanket Additional Insured Endorsement(L-723 02/09). <br /> CERTIFICATE HOLDER CANCELLATION <br /> SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE <br /> CITY OF EVERETT THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN <br /> PARKS AND COMMUNITY SERVICES ACCORDANCE WITH THE POLICY PROVISIONS. <br /> 802 EAST MUKILTEO BLVD <br /> AUTHORIZED REPRESENTATIVE <br /> EVERETT,WA 98203 _ <br /> 1i-l' /r- (JHA) <br /> I ll <br /> ©1988-2015 ACORD CORPORATION. All rights reserved. <br /> ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD <br /> Printed by JHA on May 01,2017 at 10:26AM <br />