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<br /> AWRO' MMID
<br /> (
<br /> DATE D/YYTY)
<br /> CERTIFICATE OF LIABILITY INSURANCE 0MMID018
<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 CONTACT
<br /> NAME:
<br /> Albany Office PHONE
<br /> Paynewest Insurance,Inc. (AIC,No,Ext):(541)926-4291 I WC,No):(541)9264298
<br /> 1025 Bain Street SE ADDAREESS:
<br /> Albany,OR 97322 INSURER(S)AFFORDING COVERAGE NAIC#
<br /> INSURER A:RLI Insurance Company 13056
<br /> INSURED INSURER B:Travelers Casualty&Surety Company 19038
<br /> C G Engineering, PLLC INSURERC:
<br /> 250 4th Ave S,Suite 200 INSURER D:
<br /> Edmonds,WA 98020
<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 ADDL SUBR POLICY NUMBER POLICY EFF POLICY EXP LIMITS
<br /> LTR INSD WVD (MM/DD/YYYYI (MM/DO/YYYYI
<br /> A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 2,000,000
<br /> CLAIMS-MADE X OCCUR PSB0005312 04/19/2018 04/19/2019 DAMAGE TO RENTED 1,000,000
<br /> X X PREMISES(Ea occurrence) $
<br /> MED EXP(Any one person) $ 10,000
<br /> _PERSONAL&ADV INJURY $ 2,000,000
<br /> GEN'LAGGREGATE LIMIT APPLIESPER: GENERAL AGGREGATE $ 4'000'000
<br /> POLICY X JE Q LOC PRODUCTS-COMP/OP AGG_ $ _ 4,000,000
<br /> OTHER: WA STOP GAP $ 1,000,000
<br /> COMBINED SINGLE LIMIT 1,000,000
<br /> A AUTOMOBILE LIABILITY (Ea accident)
<br /> X ANY AUTO X X PSA0002014 04/19/2018 04/19/2019 BODILY INJURY(Per person) $
<br /> OWNED SCHEDULED
<br /> AUTOS ONLY AUTOS
<br /> yE BODILY INJURY(Per accident) $
<br /> AUETOS ONLY _ AUUTOS OyNNLY (Perr acEciidentDAMAGE
<br /> $
<br /> A UMBRELLA[JAB X OCCUR EACH OCCURRENCE $ 1,000,000
<br /> X EXCESS UAB CLAIMS-MADE PSE0002337 04/19/2018 04/19/2019 AGGREGATE $ 1,000,000
<br /> DED RETENTION$ $
<br /> WORKERS COMPENSATION OTH-
<br /> AND EMPLOYERS' ABILITY YIN PER
<br /> ISTATUTE 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 /> B Professional Liab 105423530 04/01/2018 04/01/2019 Per Claim 1,000,000
<br /> B Professional Liab 105423530 04/01/2018 04/01/2019 Aggregate 2,000,000
<br /> DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required)
<br /> City of Everett,its officers,employees and agents are additional insured per attached,PPB304 0212&PPA300WA 0313,which includes primary&non
<br /> contributory and waiver of subrogation.
<br /> CERTIFICATE HOLDER CANCELLATION
<br /> SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
<br /> Ci of Everett THE EXPIRATION DATE THEREOF, NOTICE WILL BE' DELIVERED IN
<br /> City ACCORDANCE WITH THE POLICY PROVISIONS. ,
<br /> 3200 Cedar Street
<br /> Everett,WA 98201
<br /> AUTHORIZED�O� IIZ �REPRESENTATIVE
<br /> -yor
<br /> ACORD 25(2016/03) ©1988-2015 ACORD CORPORATION. All rights reserved.
<br /> The ACORD name and logo are registered marks of ACORD
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