542 MAIN-Cert of ins.pdf7
4
F
F
P
F
IF
it DATE (MM[DDIYYYY)
CERTIFICATE OF LIABILITY INSURANCE 6/22/2016
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(jes) must be endorsed. If SUBROGATION IS WAIVED, subject to
the terms and conditions of the policy, certain policies may require an endorserpent. A statement on this certificate does not confer rights to the
certificate holder In lieu of such endorsement(s). CONIAC' Ginger Carlson
PRODUCER 6 - 1FAX -5201
PHEN.E. -5200 AIC
Degginger McIntosh and Associates I, _ _ (425) 740 Nol: (425)740 —
3977 Harbour Pointe Dlvd SW E,-,',',A,L,,,,:ginger@DMAinsurance. com.
INSURER S AFFORDING COVERAGE NAIC
Mukilteo WA 98275 INSURER A 'American Economy Insurance Co. L19690
INSURED INSURER B.Ame ri can States Insurance Co.
Reliable Floor Coverings, Inc. INSURER C:
542 Main Street INSURE!&D:
-INSURER E:
,Edmond- WA 98020-3148 INSURER F :
C 11 -7 f—r UZ I ael_ TTLM Pr-vl.,;ION NUMFIFR:
LISTED BELOW HAVE BEEN
ISSUED TO
THE INSURED
NAMED ABOVE FOR THE POLICY PERIOD
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE
TERM OR CONDITION OF ANY
CONTRACT
OR OTHER
DOCUMENT WITH RESPECT TO WHICH THIS
INDICATED NOTWITHSTANDING ANY REQUIREMENT.
PERTAIN, THE INSURANCE AFFORDED BY
THE POLICIES
DESCRIBED
HEREIN IS SUBJECT TO ALL THE TERMS,
CERTIFICATE MAY 13E ISSUED OR MAY
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN
REDUCED BY
P&L—Mi-EFF
(MMIDDrr"r
PAID CLAIMS.
LMP0W=L0'CD9=X"P
LIMITS
TN -SR
TYPE OF INSURANCE
AbbLrgun
INSR
POLICY NUMBER
LTR
A
GENERAL LIABILITY
02BZ20084210
6/28/2016
6/28/2017
E H CURRENCE S 2,000,000
i5NC
A.�"gT5 RENTELP
PREMISES
S 2,000,000
_'F1_0'00A
X COMMERCIAL GENERAL LIABILITY
r
CLAIMS -MADE Fx OCCUR
x
MED EXP (Any one person)
PERSONAL & ADV INJURY
$ 2,0001000
GENERAL AGGREGATE
S 41,000,000
PRODUCTS - COMP/OP AGG
S 4,000,000
GEN'L AGGREGATE LIMIT APPLIES PER:
COMBINED SINGLE LIMI1
$
1,000,000
X1 POLICY F71 JPAC0i F_� LOC
2CE2323242
6/28/2016
6/ - 28/2017
A
AUTOMOBILE LIABILITY
BODILY INJURY (Per person)
$
ANY AUTO
ALL OWNED SCHEDULED
BODILY INJURY (Per accident)
$
AUTOS AUTOS
NON -OWNED
X
Ix
IF
PROPERTY DAMAGE
eeracSid n I
__S qj —
__qjl
$
HIRED AUTOS AUTOS
$
B
X
UMBRELLA LIAB
x
OCCUR
OISU41407570
6/28/20 16
6/28/2017
EACH OCCURRENCE
$ 1,000,000
AGGREGATE
$ 1,000,000
1
EXCESS LIAB
CLAIMS -MADE
VVC S TATU- OTH
TnRYUM1151 X 12,
S
A
02BZ20084210
6 /28/2016
6/28/2017
DED I X-1 RETENTION$ 10-000
WMPWMMMK
E.L EACH ACCIDENT
S 1 000 000
_L2��
,"P(EMPLOYERS' LIABILITY YIN
i WA STOP GAP
ANY PROPRIETORIPARTNERIEXECUTIVE I
E1. DISEASE - EA EMPLOYEE
5 1,000,000
OFFICERIMEMBER EXCLUDED?
MIA
(Mandatory in NH)
E.L. DISEASE - POLICY LIMIT
$ 1,000,000
it dpscribe tinder
gs.
0_SCRIPTION OF OPERATIONSbolow
DESCRIPTION OF OPERATIONS/ LOCATIONS I VEHICLES (Attac h AC ORD 1011, Additional Remarks Schedule, If more space in required) d
Additional Insured per attached form BP7032(0702) with respect to any an
City of Edmonds is included as
all operations of the Named Insured. All endorsements apply per required Written Contract.
4
CF_RTIt-If.;A It HULUtK
(425)771-0221
City of Edmonds
Engineering Division
121 - Sth Ave. N
Edmunds, 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
Ken M4cintosh/OGDON
� ft n nAd'^0r%r-r%00r%0ATI0N A!!rIghtsire-serve
49
if;1
4?1
il�
ACORD 25 (2010/05) a 'W IV _& —
INS(12.9; oninnsi ni T11a A rnPn nnma nnel 1,�^ %,^ iripmiat.r.4 m%rio-is ^f Ad'i'llOn
9
IF
F
11?
9
ADDITIONAL COVERAGES
Ref #
Description
Coverage Code
Form No.
Edition D#te
1-��
Employee Benefits It
EBLIA
--
Limit 1 Limit 2 Deductible Amo�-nt Deductible Type Premium
�Umlt �3
1,000
2,000,000 4,000,OOG 1,000
ef ascription Coverage Code Form No. Edition Date
Limit I Limit 2 Limit 3 ble Amount Deductible Type Premium
erage Code Form No. Edition Date
Ref # Description
�ov
Limit I UmW2 Limit 3 Deductible Amount Deductible Type Premium
Ref # Description Coverage Code Form No. Date
Limit i Limit 2 Limit 3 —[DeducibleAmount Deductible Type Premium
Ref # Description Coverage Code
Form No.
Edition Date
2 Deductible A mount Deductible Type
Limit I Limit Limit 3 lt�t mount Deductible Type
Premium
Ref #
Description r
erage Code
Form No.
Limit I
Lim it 2
Limit 3
ou-�Deductible
Dedu ctible,Amwnt
Type
Premium
Coverage Code
Form No.
Edition Date
Description
Limit 1
2
Limit 3
Deductible Amount
Deductible Type
Premium
Ref #
Description
Coverage Code
Form No.
Date
Limit I Limit 1! Limit 3 Deductible Amount Deductible Type Premium
Coverage Code Form No. Date
Ref # Description
Limit 1
It 2
Limit 3
Deductible A mountHr
e
Deductible Type
Type
Premium
-"ke-f4
Coverage Code
Form N 0
Edition Date
Description
Limit I
Urr��
Limit 2
Limit 3
Deductible mount
Deductible Type
Premium
rage Code
Form No.
Edition Date
Ref #
Description
-[&eductible
70D
Limit I
LlWi�t2 a
--
Limit 3
�.ducfible Amop nt
Type
Premium
I OFADTLCV Copyright 2001, AMS Services, Inc. I
4�
4%j
F r VY
BUSINESSOWNERS
,BP 70 32 07 02
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ rT CAREFULLY.
ADDITIONAL INSURED - OWNERS, LESSEES OR CONTRACTORS
This endorsement rriodifies insurance provided under Section 11 — Uability in
BUSINESSOWNERS COVERAG'E FORM
SCHEDULE
Name of Person or Organization:
HoJder is additional insured per written contract
(If no entry appears above, information required to complete this endorsement will be shown in the Declarations
as applicable to this endorsernent.)
WHO IS AN INSURED (Paragraph C) is amended to include a!f an insured any person or orgeNzation shown in V
the Schedule, subject to the following provisions:
11
a. The person or organization added as an insured * this endorsement is an insured only to the extent
you are hold liable due to your ongoing operations for that Insured, whether the work is performed by
yov or for you.
b. The coverage provided by this endorsement does not apply to "bodily injury" or "propert.y damage"
included within the 'products -completed operations hazard."
V c. A person's or organization's status as an insured undgr this endorsement ends when your operations
for that insured are completed.
d. No coverage �vill be provided it, in the absence of)this endorsement, no liability would be imposed by
law on you. Coverage shall be limited to the extent of your negligence or fault according to the appli-
cable principles of comparative fault.
9
4
F r
BP 70 52 07 02
C-8A.22-PRINTW Qa"14-T-L