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Home My WebLink Aboutcertificate of insurance liability.pdfMGP47LL-01-CERTIFICATEOFLIABILITYINSURANCETHISCERTIFICATEISISSUEDASAMATTEROFINFORMATIONONLYANDCONFERSNORIGHTSUPONTHECERTIFICATEHOLDER.THISCERTIFICATEDOESNOTAFFIRMATIVELYORNEGATIVELYAMEND,EXTENDORALTERTHECOVERAGEAFFORDEDBYTHEPOLICIESBELOW.THISCERTIFICATEOFINSURANCEDOESNOTCONSTITUTEACONTRACTBETWEENTHEISSUINGINSURER(S),AUTHORIZEDREPRESENTATIVEORPRODUCER,ANDTHECERTIFICATEHOLDER.IMPORTANT:IfthecertificateholderisanADDITIONALINSURED,thepolicyfies)musthaveADDITIONALINSUREDprovisionsorbeendorsed.IfSUBROGATIONISWAIVED,subjecttothetermsandconditionsofthepolicy,certainpoliciesmayrequireanendorsement.Astatementonthiscertificatedoesnotconferrightstothecertificateholderinlieuofsuchendorsement(s).CONTACTPRODUCERNAME:AlliantInsuranceServices,Inc.PHONE818WRiversideAveSte800(A/C,No,Ext):(509)325-3024,No):(5O9)325-1803E-MAILSpokane,WA99201ADDRESS:INSURER(S)AFFORDINGCOVERAGENAIC#INSURERA:LibertySurplusInsuranceCorporation10725INSUREDINSURERB:MGP47,LLCINSURERC:SRMConstruction,LLC111NPostStreet,Suite200INSURERD:Spokane,WA99201INSURERE:INSURERF:COVERAGESCERTIFICATENUMBER:REVISIONNUMBER:INSRADDLSUERPOLICYEFFPOLICYEXPTYPEOFINSURANCEINypPOLICYNUMBERMMIDDYYYY)IMMIDDIYYYY)LIMITS__________________MMERCIALGENERALLIABILITYEACHOCCURRENCE$1,000,000CLAIMS-MADEOCCUR10003224710111112I201811/1212020DAMAGETORENTEDExcludedPREMISESlEaoccurrence)$AMEDEXP(Anyonerson)$Excluded1,000,000PERSONAL&ADVINJURY$2,000,000GEN’LAGGREGATELIMITAPPLIESPER:GENERALAGGREGATE$POLICYLOCPRODUCTS-COMP/OPAGG$2,000,000—COMBINEDSINGLELIMITAUTOMOBILELIABILITYlEaaccident)$ANYAUTOBODILYINJURY(Perperson)$OWNEDIISCHEDULEDAUTOSONLYIIAUTOSBODILYINJURY(Peraccident($HIREDflNON-OWNEDPROPERTYDAMAGE$AUTOSONLYAUTOSONLY——(Peraccident)UMBRELLALIABOCCUREACHOCCURRENCE$EXCESSLIABh—iCLAIMS-MADEAGGREGATE$DEDRETENTION$——$AWORKERSCOMPENSATIONIPERII0TH-ANDEMPLOYERSLIABILITYYIN10003224710111112/20181111212020ISTATUTEIIER1,000,000ANYPROPRIETOR/PARTNER/EXECUTIVEIIEL.EACHACCIDENT$OFFICER/MEMBEREXCLUDED?L_]N!A1,000,000(MandatoryinNH)EL.DISEASE-EAEMPLOYEI-$Ifyes,describeunder1,000,000DESCRIPTIONOFOPERATIONSbelow——E.L.DISEASE-POLICYLIMIT$DESCRIPTIONOFOPERATIONS!LOCATIONS!VEHICLES(ACORD101,AddItionalRemarksSchedule,maybeattachedIfmorespaceIsrequIred)RE:104BurnettAveSouth,RentonWA98057TheCityofRentonisPrimary&Non-contributoryAdditionalInsuredperinsuringformsCG2012[5109]andCGLIO3I[4103].CERTIFICATEHOLDERCANCELLATIONSHOULDANYOFTHEABOVEDESCRIBEDPOLICIESBECANCELLEDBEFORE.THEEXPIRATIONDATETHEREOF,NOTICEWILLBEDELIVEREDINCityofRentonACCORDANCEWITHTHEPOLICYPROVISIONS.AUn:GaryBLamb,RiskMgr1055SouthGradyWayRentonWA98057AUTHORIZEDREPRESENTATIVEACORD25(2016/03)©1988-2015ACORDCORPORATION.Allrightsreserved.TheACORDnameandlogoareregisteredmarksofACORDDATE(MM!DDIYYYY)1112812018THISISTOCERTIFYTHATTHEPOLICIESOFINSURANCELISTEDBELOWHAVEBEENISSUEDTOTHEINSUREDNAMEDABOVEFORTHEPOLICYPERIODINDICATED.NOTWITHSTANDINGANYREQUIREMENT,TERMORCONDITIONOFANYCONTRACTOROTHERDOCUMENTWITHRESPECTTOWHICHTHISCERTIFICATEMAYBEISSUEDORMAYPERTAIN,THEINSURANCEAFFORDEDBYTHEPOLICIESDESCRIBEDHEREINISSUBJECTTOALLTHETERMS,EXCLUSIONSANDCONDITIONSOFSUCHPOLICIES.LIMITSSHOWNMAYHAVEBEENREDUCEDBYPAIDCLAIMS STONRIV-02CERTIFICATEOFLIABILITYINSURANCETHISCERTIFICATEISISSUEDASAMATTEROFINFORMATIONONLYANDCONFERSNORIGHTSUPONTHECERTIFICATEHOLDER.THISCERTIFICATEDOESNOTAFFIRMATIVELYORNEGATIVELYAMEND,EXTENDORALTERTHECOVERAGEAFFORDEDBYTHEPOLICIESBELOW.THISCERTIFICATEOFINSURANCEDOESNOTCONSTITUTEACONTRACTBETWEENTHEISSUINGINSURER(S),AUTHORIZEDREPRESENTATIVEORPRODUCER,ANDTHECERTIFICATEHOLDER.IMPORTANT:IfthecertificateholderisanADDITIONALINSURED,thepolicy(ies)musthaveADDITIONALINSUREDprovisionsorbeendorsed.IfSUBROGATIONISWAIVED,subjecttothetermsandconditionsofthepolicy,certainpoliciesmayrequireanendorsement.Astatementonthiscertificatedoesnotconferrightstothecertificateholderinlieuofsuchendorsement(s).CONTACTPRODUCERNAME:AlIlantInsuranceServices,Inc.PHONE(509)325-3024I(NC,No):(509)3251803818WRiversideAveSte800tAlC.No,Ext)E-MAILSpokane,WA99201ADDRESS:INSURER(S)AFFORDINGCOVERAGENAIC#INSURERA:MUtUaIofEnumclawInsuranceCompany14761INSUREDINSURERB:SRMConstruction,LLCINSURERC:111NPost,Suite200INSURERD:Spokane,WA99201INSURERE:INSURERF:COVERAGESCERTIFICATENUMBER:REVISIONNUMBER:INSRADDLSUBRPOLICYEFFPOLICYEXPTYPEOFINSURANCEgypPOLICYNUMBERfMMIDDIYYYY)IMMIDDIYYYY)LIMITS__________________OMMERCIALGENERALLIABILITYEACHOCCURRENCE$CLAIMS-MADEOCCURDAMAGETORENTEDPREMISESlEaoccurrence)$MEDEXP(Anyonepeon)$PERSONAL&ADVINJURY$GENLAGGREGATELIMITAPPLIESPER:GENERALAGGREGATE$POLICYPRO-I!LOCPRODUCTS-COMP/OPAGG$JECTUOTHER:——$AAUTOMOBILELIABILITYCOMBINEDSINGLELIMIT1,000,000lEaaccidenl)$ANYAUTOBAP000298203/05/201803/05/2019BODICYINJURY(Perperson)$OWNEDt1SCHEDULEDAUTOSONLYIIAUTOSBODILYINJURY(Peraccident)$VHIREDNON-OWNEDPROPERTYDAMAGE$AUTOSONLYAUTOSONLY—(Peraccident)$UMBRELLALIABOCCUREACHOCCURRENCE$flEXCESSLIABCLAIMS-MADEAGGREGATE$DEDIRETENTIONS$WORKERSCOMPENSATIONIPERII0TH-ANDEMPLOYERSLIABILITYISTATUTEIIERYINANYPROPRIETORIPARTNERIEXECUTIVENIAEL.EACHACCIDENT$OFFICER/MEMBEREXCLUDED?(MandatoryinNH)EL.DISEASE-EAEMPLOYEE-$Ifyes,describeunderDESCRIPTIONOFOPERATIONSbelow—EL.DISEASE-POLICYLIMIT$CERTIFICATEHOLDERCANCELLATIONSHOULDANYOFTHEABOVEDESCRIBEDPOLICIESBECANCELLEDBEFORE.THEEXPIRATIONDATETHEREOF,NOTICEWILLBEDELIVEREDINCityofRentonACCORDANCEWITHTHEPOLICYPROVISIONS.Attn:GaryBLamb,RiskMgr1055SouthGradyWayRentonWA98057AUTHORIZEDREPRESENTATIVEACORD25(2016/03)©7988-2015ACORDCORPORATION.Allrightsreserved.DATE(MM!DDIYYYY)11128/2018THISISTOCERTIFYTHATTHEPOLICIESOFINSURANCELISTEDBELOWHAVEBEENISSUEDTOTHEINSUREDNAMEDABOVEFORTHEPOLICYPERIODINDICATED.NOTWITHSTANDINGANYREQUIREMENT,TERMORCONDITIONOFANYCONTRACTOROTHERDOCUMENTWITHRESPECTTOWHICHTHISCERTIFICATEMAYBEISSUEDORMAYPERTAIN,THEINSURANCEAFFORDEDBYTHEPOLICIESDESCRIBEDHEREINISSUBJECTTOALLTHETERMS,EXCLUSIONSANDCONDITIONSOFSUCHPOLICIES.LIMITSSHOWNMAYHAVEBEENREDUCEDBYPAIDCLAIMS.DESCRIPTIONOFOPERATIONSILOCATIONSIVEHICLES(ACORD101,AddItionalRemarksSchedule,maybeattachedIfmorespaceIsrequired)RE:104BurnettAveSouth,RentonWA98057TheCityofRentonisPrimaryAdditionalInsuredperinsuringformEA9910[11/13).TheACORDnameandlogoareregisteredmarksofACORD (.k:SIAflOFWASHINGTONDepartmentofLabor&IndustriesCertificateofWorkers’CompensationCoverageNovember8,2018WAUBINo.603327920L&lAccountID368306LegalBusinessNameSRMCONSTRUCTIONLLCDoingBusinessAsSRMCONSTRUCTIONLLCWorkers’CompPremiumStatus:Accountiscurrent.EstimatedWorkersReportedQuarter3ofYear2018“0”Workers(SeeDescriptionBelow)AccountRepresentativeEmployerServicesHelpLine,(360)902-4817LicensedContractor?YesLicenseNo.SRMCOCL874O3LicenseExpiration05/10/2020Whatdoes“EstimatedWorkersReported”mean?Estimatedworkersreportedrepresentsthenumberoffulltimepositionrequiringatleast480hoursofworkpercalendarquarter.Asingle480hourpositionmaybefilledbyoneperson,orseveralparttimeworkers.IndustrialInsuranceInformationEmployersreportandpaypremiumseachquarterbasedonhoursofemployeeworkalreadyperformed,andareliableforpremiumsfoundlatertobedue.Industrialinsuranceaccountshavenopolicyperiods,cancellationdates,limitationsofcoverageorwaiverof subrogation(SeeRCW51.12.050and51.16.190). t,f1iIIf1.II.illLFt.JVfj1XJijf4.EMPLOYER:Thisofficialcertificateofindustrialinsurancecoverageisinlieuofapolicy.Itremainsineffectuntilyouraccountisofficiallyclosed.Thereisnolimitationofbenefits.Youarerequiredbylawtopostboththiscertificateandcopiesoftheposterslistedbelow.Youwillsoonbereceiving1copyofeach,ifyourequireadditionalcopies,callLaborInsuranceServicesDivisionandIndustriesat360-9024817.Emplo’erServices•JobSafetyandHealthProtection(availableinSpanish)•YourRightsasaWorker/FamilyCareDepartmentofLabor&Industhes•NoticetoEmployeesP0Box44144OlympiaWA985044144WORKER:Theemployernamedbelowisaninsuredpolicyholderwithwww.LNLwa.govtheWashingtonStateIndustrialInsuranceTrustFund.€0337UBI:PohcvEtlectiveDate1’LocationCONSTPJCLC.Employer7206THSTSOUTHSWt(O5PMC0NS)tTIONLLCKIRKLANDWA9F3033111NP051STE200SPOKANEWA932O1—’9ltI*YourUnifiedBusinessIdentifieristheonlynumberyouneedtolis,uyourbusincssaccountwiththeWashingtonstatedepartmentsofRevenue,Licensing,EmploymentSecurity,LaboiandIndustriesandtheOfficeoftheSecretaryofState.Otherstatelicensesorregistrationsmayberequiredforproperlicensingofyourbusiness.2il-l4t-OOO-(82)