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Cert of Liab Ins 07012016.pdf�� D® CERTIFICATE OF LIABILITY INSURANCE DAT 06/22/220116 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(ies) 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 CONTACT Aon Risk Services Central, Inc. PHONE FAX (800) 363-0105 0866) 283-7122 Southfield MI Office (A/C. No, Ext); (A/c No ): 3000 Town Center E-MAIL Suite 3000 ADDRESS: Southfield MI 48075 USA INSURER(S) AFFORDING COVERAGE NAIC # INSURED INSURER A: National Union Fire Ins CO of Pittsburgh 19445 Belfor USA Group, Inc.„,.„� INSURER B: AIG Specialty Insurance Company 26883 3826 woodland Park Ave N &Nd9 INSURER C: The Insurance Co of the State of PA 19429 Seattle WA 98103 USA INSURER D: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: 570062627927 REVISION NUMBER: 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. Limits shown are as requested INSR LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER OLICY EFF MM/DD/YYYY POLIC EXP MM/DD/YYYY LIMITS A X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE OCCUR X❑ GL SIR applies per policy terns & conditions 7 EACH OCCURRENCE $2,000,000 DAMAGE TO RENTED $2,000,000 PREMISES Ea occurrence MED EXP (Any one person) $10,000 PERSONAL &ADV INJURY $2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $4 , 000 , 000 POLICY PRO JECT A ILOC PRODUCTS - COMP/OP AGG $4,000,000 OTHER: A AUTOMOBILE LIABILITY CA 3194493 AOS 07/01/2016 07/01/2017 COMBINED SINGLE LIMIT $2,000,000 Ea accident) BODILY INJURY ( Per person) A X ANY AUTO CA 3194494 07/01/2016 07/01/2017 BODILY INJURY (Per accident) A OWNED SCHEDULED X AUTOS ONLY AUTOS X HIREDAUTOS NON -OWNED ONLY AUTOS ONLY MA CA 31.94495 VA 07/01/2016 07/01/2017 PROPERTY DAMAGE Per accident A X UMBRELLA LIAB EXCESS LIAB X OCCUR CLAIMS -MADE 26275184 Excess Liability 07/01/2016 07/01/2017 EACH OCCURRENCE $5,000,000 AGGREGATE $5,000,000 DED RETENTION C C WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANY PROPRIETOR / PARTNER / EXECUTIVE YIN OFFICER/MEMBEREXCLUDED'? (Mandatory in NH) N/A WCO28415783 A05 wc028415784 FL 07/01/2016 07/01/2016 07/01/2017 07/01/2017 X I STATUTE OTH IR E.L. EACH ACCIDENT $1,000,000 E.L. DISEASE -EA EMPLOYEE $1,000,000 If yes, describe under DESCRIPTION OF OPERATIONS below EL. DISEASE -POLICY LIMIT $1, 01)U, 000 DESCRIPTION OF OPERATIONS / LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) Re: For Encroachment over City sidewalk, Permit No. ENG20070331. City of Edmonds is included as Additional Insured with respect to General Liability. r N N N 0 0 r, - LO CERTIFICATE HOLDER CANCELLATION i -- SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. City Of EdmondsAUTHORIZED REPRESENTATIVE Engineering Division- p p 121 5th Avenue North c%CGtrt*.rd iLtGnea Edmonds WA 98020 USA ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD AGENCY CUSTOMER ID: 570000005415 LOC #: ADDITIONAL REMARKS SCHEDULE Page _ of AGENCY Aon Risk services Central, Inc. NAMED INSURED Belfor USA Group, Inc. POLICY NUMBER see Certificate Number: 570062627927 CARRIER See Certificate Number: 570062627927 NAIC CODE EFFECTIVE DATE: ADDITIONAL REMARKS THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, FORM NUMBER: ACORD 25 FORM TITLE: Certificate of Liability Insurance INSURER(S) AFFORDING COVERAGE NAIC # INSURER INSURER INSURER INSURER ADDITIONAL POLICIES If a policy below does not include limit information, refer to the corresponding policy on the ACORD certificate form for policy limits. INSR LTR TYPE OF INSURANCE ADDL INSD SUBR WVD POLICY NUMBER POLICY EFFECTIVE DATE MM/DD/YYYY POLICY EXPIRATION DATE (MM/DD/PYYY LIMITS WORKERS COMPENSATION C N/A wCO28415785 MA,ND,OH,WA,WI,WY 07/01/2016 07/01/2017 C N/A wc028415786 CA 07/01/2016 07/01/2017 C N/A wc028415787 AZ, VA 07/01/2016 07/01/2017 07/01/2016 07/01/2017 C N/A wc028415788 IL, KY, NC, NH, UT 07/01/2016 07/01/2017 C N/A wc02 ACORD 101 (2008/01) ©2008 ACORD CORPORATION. All rights reserv 8415789 NJ,PA 07/01/2016 07/01/2017 ed. The ACORD name and logo are registered marks of ACORD