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407 MAIN ST-CERT OF INS.pdfI'll, CI D A TE M M D D/ Y Y Y Y CERTIFICATE OF LIABILITY INSURANCE 12/08/2016 7 141S CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOTAFFIRMATIVELY 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 pol icy, 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 CONTACT NAME: _WYNN AYERS Wynn Ayers(790333A) PHONE — FAX 400 Dayton St Ste C (A/C, NO, EXT): 425-771-3535 (A/C NO)- 425-776-7353 -- ---- -- -- - E-MAIL Edmonds WA 98020-3584 ADDRESS: wayers@farmersagent.com -- — -------- . .. ......... . . INSURER(S) AFFORDING COVERAGE NAIC# INSURED INSURERA: Truck Insurance Exchange 21709 ........... ROXANNE MARLIN INSURER B: Farmers Insurance Exchange 21652 INSURERC: Mid Century Insurance Company 21687 DBA:GARDEN GATE GIFTS&HOME DECOR INSURER D: 407 MAIN ST INSURER E: EDMONDS WA 98020 INSURERF: 1. .......... ........... .. ..... .... COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: ilS iS TOCE RIIFYIHAT "I "HE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED 10 THE INSURED NAME ABOVE FOR "THE POLICY PERIOD INDICATED. NOTWI1 FISTANDING ANY ,'i-QUflR-MFNF TERM OR CONDITION OF ANY CONTRACTOR OTHER DOCUMENT" WITH RESPECT TO WHICH THIS CERTIFICATE MAYBE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLiCIES DESCRIBED HEREIN IS SUBJECTTO ALLTHE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITSSHOWN MAYHAVEBEEN REDUCED BY PAID CLAIMS. INSR ADDTL SUBR i EFF POLICY EXP TYPE OF INSURANCE POLICYNUMBER LIMITS L:rR INSID WVD (MM/DD/YYYY) (MM/DD/YYYY COMMERCIAL GENERAL LIABILITY ......... . . . CLAIMS -MADE X I OCCUR C GEN'L AGGREGATE LIMIT APPLIES PER: POLICY PROJECT LOC .......... 0 1 HER: .... . ...... ..... ------ AUTOMOBILE LIABILITY ANY AUTO OWNED AUTOS ONLY I IRED AUTOS ONLY SCHEDULED AUTOS NON -OWNED AUTOS ONLY Y 1 Y :605891352 1 01/30/2017 01/30/2018 UMBRELLA LIAB OCCUR EXCESS LIAB CLAIMS MADE I DLD I RETEN-11ON$ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANY PROPRIETOR/PARTNER/ Y/N EXECUTIVE OFFICER/MEMBER N/A EXCLUDED? (Mandatory in NH) Yves, describe under DESCRIPTION OF OPERATIONS below EACH OCCURRENCE $ 1,000,000 DAMAGE TO RENI ED $ PREMISES (Ea Occurrence) 75,000 MED EXP (Any one person) .................. ............. $ 5,000 I PERSONAL &AIDV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 PRODUCTS COMP/OPAGG ........... $ 1,000,000 COMBINED SINGLE LIMIT $ (Ea accident) BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ PROPERTY DAMAGE $ (Per accident) EACH OCCURRENCE AGGREGATE PER OTHER $ STATUTE E.L. EACH ACCIDENT $ ..... ........ --71 E.L.DISEASE-EAEMPLO - E.L. DISEASE - POLICY LIMIT --- — ------------- DESCRIPTION OF OPERATIONS/1-OCATIONS/VEHICLES (ACORD 101, Additional Remarks Schedule, maybe attached if more space is required) 407 MAIN ST EDMONDS, WA 98020 IT IS UNDERSTOOD AND AGREED THAT THE CITY OF EDMONDS IS NAMED AS AN ADDITIONAL INSURED FOR THE STREET USE PERMIT LOCATED AT 407 MAIN ST., EDMONDS WA, IN THE CITY RIGHT-OF-WAY. CERTIFICATE HOLDER ENGINEERING DIVISION 121 5TH AVENUE N CANCELLATION - - - ------ ------- -- - SHOULD ANY OFTHE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIJERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE k A ACORD 25 (2016/03) � 1 1769 11 15 @1988-2015Ar.01113CORPORNT11 N. All Rights Reserved 1 The ACCIRD name and logo are registered marks of ACORD POLICY NUMBER: 605891352 BUSINESSOWNERS THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - STATE OR POLITICAL SUBDIVISIONS - PERMITS RELATING TO PREMISES This endorsement modifies insurance provided under the following: BUSINESSOWNERS POLICY SCHEDULE* State or Political Subdivision: CITY OF EDMONDS ENGINEERING DIVISION The following is added to Paragraph C. WHO IS AN a. The existence, maintenance, repair, construc- INSURED in the Businessowners Liability Coverage tion, erection, or removal of advertising signs, Form: awnings, canopies, cellar entrances, coal 4. Any state or political subdivision shown in the holes, driveways, manholes, marquees, hois- Schedule is also an insured, subject to the follow- taway openings, sidewalk vaults, street ban- ing additional provision: ners, or decoration and similar exposures; This insurance applies only with respect to the b. The construction, erection, or removal of ele- following hazards for which the state or political vators; or subdivision has issued a permit in connection with c. The ownership, maintenance, or use of any premises you own, rent, or control and to which elevators covered by this insurance. this insurance applies: Information required to complete this Schedule, if not shown on this endorsement, will be shown in the Decla- rations. BP 04 07 01 87 Copyright, Insurance Services Office, Inc., 1985 Page 1 of 1 ❑ THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY E3306 - ' WAIVER OF TRANSFER OF RIGHTS OF RECOVERY 1st Edition AGAINST OTHERS TO US 10/21/15 60589-13-52 Effective Date Policy Number This endorsement modifies insurance provided under the following: BUSINESSOWNERS COMMON POLICY CONDITIONS - BP 00 09 SCHEDULE Name of Person or Organization: CITY OF EDMONDS ENGINEERING DIVISION tiff no entry appears above, information required to complete this Endorsement must be shown in the Declarations as applicable to ,his endorsement.) The provisions of the Businessowners Common Policy Conditions are modified by this endorsement as follows. - Condition K. Transfer Of Rights Of Recovery Against Others To Us in the Businessowners Common Policy Conditions is amended by the addition of the following: 3. We waive any right of recovery we may have against the person or organization shown in the Schedule above because of payments we make for injury or damage arising out of your ongoing operations or "your work" done under a contract with that person or organization and included in the "products -completed operations hazard." This waiver applies only to the person or organization shown in the Schedule a bove. This endorsement is part of your policy. It supersedes and controls anything to the contrary. It is otherwise subject to all the terms of the policy. 91-3306 '1ST EDITION 6-97 Includes Copyright Material Insurance Services Office, Inc., 1992 E3306101 PAGE 1 OF 1 Attach to your policy with the same policy number shown on this endorsement. ENDORSEMENT Effective Date 01/30/16 60589-13-52 Policy Number of the Company designated in the Declarations THE CITY OF EDMONDS ENGINEERING DIVISION IS ADDED AS ADDITIONAL INSURED FOR PRIMARY AND NON CONTRIBUTORY COVERAGE :,SING THE FORM "ADDITIONAL INSURED- STATE OR POLITICAL SUBDIVISIONS- PERMITS RELATING TO PREMISES.° LOCATION: 407 MAIN ST EDMONDS, WA This endorsement is part of your policy. It supersedes and controls anything to the contrary. It is otherwise subject to all other terms of the policy. COUNTERSIGNED (Date) x -0002 (E 0002) 1ST EDITION 3-88 FkRMERS ��1XSURAXCE� �� GNOUF THIS ENDORSEMENT IS ATTACHED TO AND MADE PART OF YOUR POLICY IN RESPONSE TO THE DISCLOSURE REQUIREMENTS OF THE TERRORISM RISK INSURANCE ACT. THIS ENDORSEMENT DOES NOT GRANT ANY COVERAGE OR CHANGE THE TERMS AND CONDITIONS OF ANY COVERAGE UNDER THE POLICY. t �. 16300 FARMERS 3rd Edition INSURANCE DISCLOSURE PURSUANT TO TERRORISM RISK INSURANCE ACT SCHEDULE SCHEDULE -PART[ Terrorism Premium (Certified Acts) $ 4.00 Additional information, if any, concerning the terrorism premium: SCHEDULE - PART II Federal share of terrorism losses 84 % Year: 2016 (Refer to Paragraph B. in this endorsement) Federal share of terrorism losses 83 % Year: 2017 (Refer to Paragraph B. in this endorsement) Information required to complete this Schedule, if not shown above, will be shown in the Declarations. A. Disclosure Of Premium In accordance with the federal Terrorism Risk Insurance Act, we are required to provide you with a notice disclosing the portion of your premium, if any, attributable to coverage for terrorist acts certified under the Terrorism Risk Insurance Act. The portion of your premium attributable to such coverage is shown in the Schedule ofthis endorsement or in the policy Declarations. B. Disclosure Of Federal Participation In Payment Of Terrorism Losses The United States Government, Department of the Treasury; will pay a share of terrorism losses insured under the federal program. The federal share equals a percentage (as shown in Part II of the Schedule of this endorsement or in the policy Declarations) of that portion of the amount of such insured losses that exceeds the applicable insurer retention. However, if aggregate insured losses attributable to terrorist acts certified under the Terrorism Risk Insurance Act exceed $100 billion in a calendar year the Treasury shall not make any payment for any portion of the amount of such losses that exceeds $100 billion. C. Cap On Insurer Participation In Payment Of Terrorism Losses If aggregate insured losses attributable to terrorist acts certified under the Terrorism Risk Insurance Act exceed $100 billion in a calendar year and we have met our insurer deductible under the Terrorism Risk Insurance Act, we shall not be liable for the payment of any portion of the amount of such losses that exceeds $100 billion, and in such case insured losses up to that amount are subject to pro rata allocation in accordancewith procedures established by the Secretary of the Treasury. 93-6300 3RD EDITION 1-15 Includes Copyright Material of Insurance Services Office, Inc., with its permission J6300301 PAGE 1 OF 1 J6300-ED3