Cert of ins.pdfINSURANCE I3�18/2017)
CERTIFICATE OF LIABILITY
--�
DATE lD4vf/DD/
,
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 OR PRODUCER, AND THE CERTIFICATE HOLDER. ___
IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the olic ies must have ADDITIONAL provisions or be
P y( ) TIONAL INSURED rovisi 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 TictNtttdoretrlL Itt(s).
m u
to the certificate holder lieu of such a MM
INSURANCE SERVICES GROUP INC/PHS
811422 P: (866) 467-8730 F: (888)
PO BOX 33015
SAN ANTONIO TX 7
8265
INSURED
k ,,o
Ext(86646
0
IT. .....
443-6112 Ao;co'RNS
WALNUT ST COFFEE LLC
HAI? 2 It 2017
19304 21ST AVE NW -EFUNG DIVISION
SHORELINE WA 98177
No): (888) 443-6112
NAIC#
LOTH
I
11
SONAMED
THAT THE POLICIES
OIF
NSURANICE
LISTED BELOW HAVE
BEEN ISSUED
TO THE INSURED
ABOVE FOR THE POLICY PERIOD
SRISGOSCERTIFY
NOTWITHSTANDING ANY REQUIREMENT,
TERM OR CONDITION
OF ANY CONTRACT
OR OTHER DOCUMENT
WITH RESPECT TO WHICH THIS
INDICATED.
CERTIFICATE
MAY BE ISSUED OR MAY
PERTAIN,
THE INSURANCE AFFORDED
BY THE
POLICIES DESCRIBED
HEREIN IF, SUBJECT TO ALL THE
TERMS,EXCLUSIONS
AND CONDITIONS OF
SUCH
POLICIES.
LIMITS SHOWN MAY
HAVE BEEN REDUCED
BY PAID CLAIMS„
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POLL F�
LL�IITS
,
.............. ...
EACH OCCURRENCE
C ,
2 0 0 0, 0 0 0
COMMERCIAL GENERAL LIAB WTY
p
x�OCCUR
DAMAGE TOI6F-PJCL&1 300 000
CLAIMS—MADE V
ES Qk '� m�;`u I,Nc¢a,ntsal
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x General Liab
x
52 SBA IX0766
02/°4/2017
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02 24/2016
/
MEDny
P (Any one person) 10 , 0 00
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....,
PERSONAL & ADV INJURY 2. r...0 0 0, 0 0,0.....
GATE 4 000, 000
GENPOLICYp ¢,A ['��? PRO PLIES PER:
EMIT AP LOC
PRODUC .P/OP AG n 4 , 0 0,0 , 0 00 �..
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OTHER
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f(F 0 0 0 0 0
AUTOMOBILE LIABILITY
a accident)
ANY AUTO
BODILY INJURY (Per person)
OWNED .,...' SCHEDULED
�2_ SBA IX0768
5
0' / 2 4 / 2 017
0 2 / 2 4 / � OI 8
(Per accident)
(
AUTOS ONLY AUTOS
x HIRED J� NON -OWNED
__
PROPERTY DAMAG�� - .........
E
AUTOS ONLY AUTOS ONLY
( ,,,.i�tn"eeM
Per IIti..�, .....__....._. ..,,,., ... .........----
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UMBRELLA UR
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-
EACH OCCURRENCE.,
EXCESS LIAB CLAIMS MADE
AGGREGATE
KIgF IIfUlI gtw'JF7$
.
WORSENS COMPENSAVON
I �m I{ �OTH
�C+rs'61 dEi ER
AND EWPL0MRS'LLARZLnT
ANY PROPRIETOR/PARTNER/EXECUTIVEY/N
... „
E L EACH ACCIDENT " 1, 000, 000
A
OFFICER/MEMBER EXCLUDED? ---
(Mandatory in NH)
MA
52 SBA IX0768
02/24/2017
02/24/2018
EL DISEASE EA EMPLOYEE , 0, 000
, ........ ........
........
If yes, describe under
E L DISEASE - POLICY LIMIT $ , , 0
001. 0
1 0 0
DESCRIPTION OF OPERATIONS below
DESCR/PT70N
OFOPERAT/ONS/LOCATIONS/ VEHI�RD
i01,
Additional Remarks Schedule, may
be attached if more
space is required)
- mm --
Those
usual to the Insured's
Operations. Re:
Wall Mount
Sign,
Flower Box and
Seasonal
Outdoor Charis
located
in the City
right of
gray; 410
Walrixit:. St
Edmonds,
WA as per street
use
permit # eng
20060.145 and
encroachment
permit #
encs
201"103(:)8. Certificate
Holder
is an Additional
Insured
per
the Business
Liability
Coverage Form
SS0008
attached to
this policy_
reserved.