Jean Bergo 12/10/2018 - Laserfiche WebLink

• ® DATE(MM/DD/YYYY) A C� CERTIFICATE OF LIABILITY INSURANCE 11/29/2017 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(ies)must have ADDITIONAL INSURED provisions or 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). CONT PRODUCER Liberty Mutual Insurance NAMEACT PO Box 188065 PHONE FAX Fairfield, OH 45018 E-MAIL IL Extl: 800-962-7132 (wc,No): 800-845-3666 ADDRESS: BusinessServiceALibertyMutual.com INSURER(S)AFFORDING COVERAGE NAIC# INSURER A: Ohio Security Insurance Company 24082 INSURED INSURER B: Jean Bergo 19504 53rd Ave NE INSURER C: LK Forest PK WA 98155 INSURERD: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: 39002737 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 ADDL SUBR POLICY EFF POLICY EXP LIMITS LTR INSD WVD POLICY NUMBER (MM/DD/YYYY) (MM/DD/YYYY) A ✓ COMMERCIAL GENERAL LIABILITY ✓ BKS54951601 11/1/2017 11/1/2018 EACH OCCURRENCE $1,000,000 DAMAGE RETED CLAIMS-MADE ,/ OCCUR PREM SESO(Ea occurrence) $1,000,000 MED EXP(Any one person) $15,000 PERSONAL&ADV INJURY $1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $2,000,000 ✓ POLICY JET LOC PRODUCTS-COMP/OPAGG $22000,000 OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ (Ea accident) ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS HIRED NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY AUTOS ONLY (Per accident) UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY Y/N STATUTE ER ANYPROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ OFFICER/MEMBEREXCLUDED? N/A (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) City of Everett and Everett Senior Center are Additional Insured if required by written contract or written agreement subject to General Liability Blanket Additional Insured Provision. CERTIFICATE HOLDER CANCELLATION Cityof Everett SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Everett Senior Center ACCORDANCE WITH THE POLICY PROVISIONS. 3025 Lomard Everett WA 98201 AUTHORIZED REPRESENTATIVE L"-kYV Tracey Lynn ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD 39002737 154951601 117-10 Master Certificate 1 Tracey Lynn 111/29/2017 9:19:31 AM (PST) 1 Page 1 of 9