410 WALNUT ST-Cert of ins.pdfATE
CERTIFICATE OF LIABILITY INSURANCE 1/2 /2017)
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THIS CERTIFICATEIS 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 ER HOLDER. _m If IMPORTANT:
If SUBROGATION IS
certificate ate holden is an ADDIT ADDITIONAL INSURED, the policy(ies)Wmust have ADDITIONAL INSURED provisions or be endorsed.
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 end+orsementi s).
URRY & ROGERS
INS AGCY
INC/PHS
(rc No Ext> (866) 467 8730 �
(888) 443 611-
2
811637 P: (866)
467-8730
F: (888)
443-6112
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A—DD5E_95:
PO BOX 33015
SURER(S) AFFORDING COVERAGE NAICN
AN ANTONIO TX
78265
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Ins Co
Hartford Casualty..,._..._._.—_.,.. � ...•.�_— ��. ._we,_
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INSURERA:
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INSURER C
WALNUT ST COFFEE
LLC
9N1H
D,.
INSURER
19304 21ST AVE
NW
Mi
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INSURERE;
SHORELINE WA 98177
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INSURER F;
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_ CERTIFICATE
NUMBER:
REVISION
NUMBER:
THIS IS P
TO CERTIFY THAT THE OLICIESINSURANCE
OF
_
INSURANCE
.
LISTED BELOW HAVE
�•.� .YY.»> __'
BEEN ISSUED
..min.. "
TO THE INSURED
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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.
TYPE OFINSURANCE
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POLICYNUMRER
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POLICYEXP
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LIMITS
COMMERCIAL GENERAL LIABILITY
OCCURRENCEP2,000,000
CLAX OCCUR
i�Li ��
DAMAGE
PREMISES �a ' 00 000
_ (E° a c a�raeama�o� r
A X General b
X
52 SBA VW7166
02/24/2017
02/24/2018
.... .....
MED EXP (Any one person)
,,10 P ) , 000
PERSONAL & ADV INJURY 2, 0 0 0, 0 0 0
a I1 LIMIT APPLIES PER:
GENERAL, 4, 0 0 0, 000 0
LSGGREGA
I PRO- X LOC
l JECT �_..,
P AGG 4, 0 0 0, 0 0 0
OTOHER6�E.
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A
AUTOMOBILE LIABILITY
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.........da 2 ..
COMBINED „�.....,
SINGLE LIMhI C"
000, 000
QF.a �RdS.M'Wa'�
ANYAUTO
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'BODILY INJURY (Per person)
OWNED
A AUTOS ONLY �''AUTOSULED
52 SBA VW7166
02/24/2017
02/24/2018
BODILY INJURY(Peraccident)
HIRED NON -OWNED
AUTOS ONLY AUTOS ONLY
PROPERTY DAMAGE
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UMBRELLA LIAB OCCUR
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..
�.. ... w_�. _
....
.,..�Y.... ...�_
EACH OCCURRENCE ;
EXCESS LIAB CLAIMS -MADE
AGGREGATE
rr� ata� s
a
WORKEIi5COMPEN5A770N
ANDE,wamrexs•LrAelcrTY
R
ANY PROPRIETOR/PARTNERIEXECUTIVEY/N
OFFICER/MEMBER
E.L. EACH tR _ ...--
H ACCIDENT 11, 0 0 0 000
EXCLUDED? __�.,.qp
wA
�
�
A (Mandatory in NH) [A
52 SBA VW7166
02/Z4/2017
02/24/2018 IE.L.DISEASE-
EAEMPLOYE 1, 0 0 0 000
If yes, descnbe under low
DESCRIPTION OF Q.dP LRATIONS be
—
,
E L. DISEASE POLICY LIMIT 1 , 000, 000
d"]M�'r4%I�lf3I'JCII+i ........•••����
OF OPERATIONS / LOCATIONS / VEHI C(O
.BR
D 101,
Additional Remarks Schedule, may
be attached if more
'
space '
Is required)
Ired)
••••••••••�. ..........��•
Those usual to the Insured's
Operations. Re:
Wall Mount
Sign, Flower
Box and
Seasonal Outdoor Charis
located
in the City
right of
way; 410 Walnut
St
Edmonds, WA as per street
use
permit # eng 20060145
and
encroachment
permit #
20110308. Certificate
Holder
is an Additional
Insured
per the
Business
,eng
Liability Coverage Form
SS0008
attached to this
policy.
CFRTIFIrATF 41n1 r1F....
_ R
City of Edmonds
Engineering Division
121 5TH AVE N
EDMONDS, WA 98020
_CANCELLATION _
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES ... ��. ......................ww.�..w_. �...C..............
DESCRIBED BE CANCELLED
BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE
DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS.
AUT1-IORIZF1'1 REPRESENTATIVE.....�..............��'__..�._........,.,.........�...............�.r�w
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