201 5 AVE S-CERT OF INS.pdfyi,,, �+ L (i AMU
ACOR" CERTIFICATE OF LIABILITY INSURANCE
DATE (MMIDDIYYYY)
12/16/2016
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(les) 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).
PRODUCER
Pacific Underwriters Corp.
12611 Des Moines Mem. Dr.
CONTACT Angela Anderson
NAME:.— g —
PHONE 206 248-2254 FAX No): (206) 248-0130
A/C Nom) ( ) – —
E-MAIL ss: aanderson acificunderwriters.com _.
INSURERS) AFFORDING COVERAGE NAIC #—
PO Box 68787
Seattle, WA 98168
INSURERA: Continental Casualty Compan
INSURED
Eric D. Kitts, DDS ,
INSURER B: ..—
—_--_
INSURER C : —
—_—.--
INSURER D: _
201 5th Ave. S. #103
Edmonds, WA 98020 ENCANEERING DIVISON,INSURER
__
E : —__ --
INSURER F:
RII IRR[fCO.
GEN'L
COVERAGES I CKI It'I4:1AIC IVUIVIDUM. •----- -'
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
LTR
A
TYPE OF INSURANCE
COMMERCIAL GENERAL LIABILITY
TCLAIMS-MADE r OCCUR
ADDL
Y
SUBR
POLICY NUMBER
297106911
POLICY EFF
MM/DD/YYYY
01/01/2017
POLICY EXP
MM/DDIYYYY
01 /01 /2018
LIMITS
_ EACH OCCURRENCE
DAMAGE TO RENTED
PREMISES Ea occurrence
$1,000,000
$ 500,000
MED EXP (Any one person)
$ 10,000
PERSONAL & ADV INJURY
$ Included
GENERAL AGGREGATE
$3,000,000
GEN'L
AGGREGATE LIMIT APPLIES PER:
POLICY ❑ JE 0 E] LOC
OTHER:
LIABILITY
ANY AUTO
OWNED SCHEDULED
AUTOS ONLY AUTOS
HIRED NON -OWNED
AUTOS ONLY AUTOS ONLY
PRODUCTS - COMP/OP AGG
$1,000,000
COMBINED SINGLE LIMIT
Ea accident
$
AUTOMOBILE
_....._
BODILY INJURY (Per person)
$
BODILY INJURY (Per accident)
$ —
PROPERTY DAMAGE
Per accident)
—
$
UMBRELLA LIAB
EXCESS LIAB
OCCUR
CLAIMS -MADE
N/A
EACH OCCURRENCE
$
AGGREGATE
$ —
PER OTH-
STATUTE I ER
-
DED RETENTION $
WORKERS COMPENSATION
AND EMPLOYERS' LIABILITY Y / N
ANYPROPRIETOR/PARTNER/EXECUTIVE
.OFFICER/MEMBER EXCLUDED?
(Mandatory In NH)
If yes, describe under
DESCRIPTION OF OPERATIONS below
E.L. EACH ACCIDENT
$
F.L. F.MPL.OYEE
DISEASE - EA
$ _ —
E.L. DISEASE -POLICY LIMIT
$
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required)
It is understood and agreed that the City of Edmonds is named as an additional insured. Permit ENG20110133 for sign located in the City
right-of-way.
:l le pl;g
City of Edmonds
Additional insured: Engineering Division
121 5th Ave N
Edmonds, WA 98020
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
AUTHORIZED REPRESENTATIVE
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ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD