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Certificate of Liability.pdf
Af3RI3CERTIFICATEOFLIABILITYINSURANCETHISCERTIFICATEISISSUEDASAMAHEROFINFORMATIONONLYANDCONFERSNORIGHTSUPONTHECERTIFICATEHOLDER.THISCERTIFICATEDOESNOTAFFIRMATIVELYORNEGATIVELYAMEND,EXTENDORALTERTHECOVERAGEAFFORDEDBYTHEPOLICIESBELOW.THISCERTIFICATEOFINSURANCEDOESNOTCONSTITUTEACONTRACTBETWEENTHEISSUINGINSURER(S),AUTHORIZEDREPRESENTATIVEORPRODUCER,ANDTHECERTIFICATEHOLDER.IMPORTANT:IfthecertificateholderisanADDITIONALINSURED,thepolicy(ies)musthaveADDITIONALINSUREDprovisionsorbeendorsed.IfSUBROGATIONISWAIVED,subjecttothetermsandconditionsofthepolicy,certainpoliciesmayrequiteanendorsement.Astatementonthiscertificatedoesnotconferrightstothecertificateholderinlieuofsuchendorsement(s).PRODUCERCONTACTNAME:JosephLaParneJosephLaParnePHONEFAX1070NWMurrayRdSte6(A/C,NO,EXr):971-228-8966(A/C,NO):503-961-7530Portland,OR97229E-MAILADDRESS:jlaparne@farmersagent.ComINSURER(S)AFFORDINGCOVERAGENAIC#INSUREDINSURERA:SeCUrityNationalInsuranceCompany19879INSURERB:MallWilson,DBA:Engine,LLCINSURERC:19243SE259thP1INSURERD:Covington,WA98042INSURERE:INSURERF:COVERAGESCERTIFICATENUMBER:REVISIONNUMBER:INSRADDTLSUeRPOLICYEFFPOLICYEXPTYPEOFINSURANCEPOLICYNUMBERLIMITSLTRINSD:WVD(MM/DD/YYYY)(MM!DD/YYYY)CLAIMS-MADEXOCCURDAMAGETORENTEDPREMISES(EaOccurrence)$100,000XOMMERcIALGENERALLIABILITYEACHOCCURRENCE$1,000,000-JMEDEXP(Anyoneperson)$5,000XNA11502620103/7/201803/7/2019PERSONAl&AOVINJURY$1,000,000GEN’LAGGREGATELIMITAPPLIESPER:GENERALAGGREGATE$1,000,000[POLICYPROJECTLOCPRODUCTS-COMP/OPAGG$1,000,000COMBINEDSINGLELIMITAUTOMOBILELIABILITY$(Laaccident)ANYAUTOBODILYINJURY(Perperson)$OWNEDAUTOSSCHEDULEDBODILYINJURY(Peraccident)$ONLYAUTOSHIREDAUTOSNON-OWNEDPROPERTYDAMAGE$ONLYAUTOSONLY(Peraccident)5UMBRELLALIABOCCUREACHOCCURRENCE$EXCESSLIABCLAIMS-MADEAGGREGATE$DEDRETENTION$$WORKERSCOMPENSATIONIPEROTHER$ANDEMPLOYERS’LIABILITYSTATUTEANYPROPRIETOR/PARTNER!V/NEL.EACHACCIDENT$EXECUTIVEOFFICER/MEMBERrN/AEXCLUDED?(MandatoryinNH)[EL.DISEASE-EAEMPLOYEEIfyes,describeunderDESCRIPTIONOFEL.DISEASE-POLICYLIMIT$OPERATIONSbelowDESCRIPTIONOFOPERATIONS/LOCATIONS!VEHICLES(ACORD101.AdditionalRemarksSchedule,maybeattachedifmorespaceisrequired)Excavatingandmovingearthinpreparationforworkplannedbygeneralcontractors.CERTIFICATEHOLDERCANCELLATIONAdditionalinsured:CItyofRentonSHOULDANYOFTHEABOVEDESCRIBEDPOLICIESBECANCELLEDBEFORETHEEXPIRATIONAUN:RohiniNair,DeptofCommUnityandDATETHEREOF,NOTICEWILLBEDELIVEREDINACCORDANCEWITHTHEPOLICYPROVISIONS.IEconomicDevelopment.1055S.GradyWayAUTHORIZEDREPRESENTATIVEJosephLaParneRenton,WA9R057]ACORD25(2016/03)31-176911-15©1988-2015ACORDCORPORATION.AllRightsReservedTheACORDnameandlogoareregisteredmarksofACORDDATE(MM/DD/YYYY)05/01/2018THISISTOCERTIFYTHATTHEPOLICIESOFINSURANCELISTEDBELOWHAVEBEENISSUEDIOTHEINSUREDNAMEABOVEFORTHEPOLICYPERIODINDICATED.NOTWITHSTANDINGANYRFOUIRFMFNT,TFRMORCONDITIONOFANYCONTRACTOROTHERDOCUMFNTWITHRFSPECTTOWHICHTHISCERTIFICATEMAYREISSUEDORMAYPERTAIN,THEINSURANCEAFFORDEDBYTHEPOLICIESDESCRIBEDHEREINISSUBJECTTOALLTHETERMS.EXC..USIONSANDCONDITIONSOFSUCHPOLICIES.LIMIT5SHOWNMAYHAVEBEENREDUCEDBYPAIDCLAIMS.