|
A�® CERTIFICATE OF LIABILITY INSURANCE DATE(MWDDrYYY)
<br /> 10/5/2018
<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 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 CONTACT Debbie COOk
<br /> NAME:
<br /> Leavitt Group Northwest (A/C,NNo,Ext): (800)726-8771 a/c,No):(866)728-9168
<br /> PO Box 65770 E-MAIL
<br /> ADDRESS:debbie-cook@leavitt.com
<br /> INSURER(S)AFFORDING COVERAGE NAIC 8
<br /> University Place WA 98464 INSURERA:Great American Insurance Company C16691
<br /> INSURED INSURER B:
<br /> Domestic Violence Services of Snohomish County INSURER C:
<br /> PO Box 7 INSURER D:
<br /> INSURER E:
<br /> Everett WA 98206-0007 INSURERF:
<br /> COVERAGES CERTIFICATE NUMBER:18-19 Master 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 SPOLICY NUMBER (MM/D/YYYY) (MM/D/YYYY) LIMITS
<br /> POLICY EFF POLICY EXP
<br /> LTR INSD' VD
<br /> X COMMERCIAL GENERAL LIABILITY 1 I
<br /> EACH OCCURRENCE $ 1,000,000
<br /> , DAMAGE
<br /> A CLAIMS-MADE X OCCUR PREM SESO(EaENTEoccur ence) $ 100,000
<br /> X PAC059525505 10/10/2018 10/10/2019 MED EXP(Any one person) $ 5,000
<br /> PERSONAL 8 ADV INJURY $ 1,000,000
<br /> GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000
<br /> PRO LOC PRODUCTS-COMP/OP AGG $ 2,000,000
<br /> X POLICY JECT
<br /> OTHER: Stop Gap Employee BI by �$ 1,000,000
<br /> AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ 1,000,000
<br /> (Ea accident)
<br /> A X ANY AUTO BODILY INJURY(Per person) $
<br /> ALL OWNED SCHEDULED CAP59525605 10/10/2018 10/10/2019 BODILY INJURY(Per accident) $
<br /> AUTOS AUTOS
<br /> NON OWNED PROPERTY DAMAGE $
<br /> HIRED AUTOS AUTOS (Per accident)
<br /> Underinsured motorist $ 1,000,000
<br /> UMBRELLA LIAB X OCCUREACH OCCURRENCE __ l$ 2,000,000
<br /> A EXCESS LIAB CLAIMS-MADE AGGREGATE $ 2,000,000
<br /> DED X RETENTION 10,000 UNB59525705 10/10/2018 10/10/2019 $
<br /> WORKERS COMPENSATION PER I STATUTE x OETH
<br /> AND EMPLOYERS'LIABILITY Y/N --_-_--- -_ - - --ANY PROPRIETOR/PARTNER/EXECUTIVE - --- WA Stop Gap E.L.EACH ACCIDENT $ _1,_000,000_
<br /> OFFICER/MEMBER EXCLUDED? N/A E-EA E
<br /> PAC059525505 10/10/2018 10/10/2019 E.L.DISEASE $ 1,000,000
<br /> A (Mandatory in NH)
<br /> If yes,describe under
<br /> DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT I $ 1,000,000
<br /> DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required)
<br /> The City of Everett, Its officers, employees and agents are named as an additional insured as per terms
<br /> and conditions of form CG2026 04 13 attached.
<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 /> 2930 Wetmore Ave Ste #8A ACCORDANCE WITH THE POLICY PROVISIONS.
<br /> Everett„ WA 98201
<br /> AUTHORIZED REPRESENTATIVE
<br /> Jeff Olsen/DECOOK 4S1g2, 0
<br /> ©1988-2014 ACORD CORPORATION. All rights reserved.
<br /> ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD
<br /> INS025(201401)
<br />
|