DNS SEE APPROVED PERMIT PACK ENG2024-0502+Certificate_of_Liability_Insurance+10.23.2024_11.45.05_AM+4576710/
AC"R " CERTIFICATE OF LIABILITY INSURANCE
DATE (MM/DDIYYYY)
08/01 /2024
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 Kari DiJulio
NAME:
Gurry&Rogers Insurance Agency, Inc.
AIIC, o (206) 621-6444 (AIXC (206) 515-0560
No,Ext : No):
2901 NE Blakeley St. #3A
E-MAIL kari@gurryandrogers.com
ADDRESS:
INSURER(S) AFFORDING COVERAGE
NAIC #
INSURERA: Travelrs Indemnity Co of Conn
25682
Seattle WA 98105
INSURED
INSURER B :
East West Bookshop Of Seattle
INSURER C :
INSURER D :
110 3rd Ave N
Ste 102
INSURER E :
INSURER F :
Edmonds WA 98020-3202
COVERAGES CERTIFICATE NUMBER: CL2172004496 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 CONTRACTOR 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
TYPE OF INSURANCE
INSD
WVD
POLICY NUMBER
POLICY EFF
(MM/DD/YYYY)
POLICY EXP
(MMIDD/YYYY)
LIMITS
X
COMMERCIAL GENERAL LIABILITY
EACH OCCURRENCE
$ 2,000,000
CLAIMS -MADE � OCCUR
DAMAGE
PREM SESO(Ea occurrence)
$ 300,000
_7RETED
MED EXP (Any one person)
$ 5,000
PERSONAL&ADV INJURY
$ 2,000,000
A
Y
Y
6808498H106
01/30/2024
01/30/2025
GEN'LAGGREGATE LIMITAPPLIES PER:
GENERAL AGGREGATE
$ 4,000,000
X POLICY JJECT LOC
PRODUCTS - COMP/OP AGG
$ 4,000,000
$
OTHER:
AUTOMOBILE
LIABILITY
COMBINED SINGLE LIMIT
(Ea accident)
$ 2,000,000
BODILY INJURY (Per person)
$
ANY AUTO
A
OWNED SCHEDULED
AUTOS ONLY AUTOS
Y
Y
6808498H106
01/30/2024
01/30/2025
BODILY INJURY (Per accident)
$
X
PROPERTY DAMAGE
(Per accident)
$
HIRED X NON -OWNED
AUTOS ONLY AUTOS ONLY
UMBRELLA LIAB
OCCUR
EACH OCCURRENCE
$
AGGREGATE
$
EXCESS LIAB
CLAIMS -MADE
DED I I RETENTION $
$
A
WORKERS COMPENSATION
AND EMPLOYERS' LIABILITY Y / N
ANY PROPRIETOR/PARTNER/EXECUTIVE
OFFICER/MEMBER EXCLUDED? ❑
(Mandatory in NH)
N/A
Y
6808498H106-WA Stop Gap
01/30/2024
01/30/2025
PER �/ OTH-
STATUTE ER
E.L. EACH ACCIDENT
1,000,000
$
E.L. DISEASE - EA EMPLOYEE
$ 1,000,000
If yes, describe under
DESCRIPTION OF OPERATIONS below
E.L. DISEASE - POLICY LIMIT
1,000,000
$
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 additional insured located at 110 3rd Ave N, Ste 102, Edmonds, WA, 98020 in the City
right-of-way.
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
City of Edmonds
ACCORDANCE WITH THE POLICY PROVISIONS.
Engineering Division
AUTHORIZED REPRESENTATIVE
121 5th Avenue North
Edmonds WA 98020
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