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HomeMy WebLinkAboutLW11-029 - Insurance Certificate - Friendship Diversion Services - 07/01/2014-07/01/2015 Liability Coverage - 07/01/2014 DATE(MM/DD/YYYY) AC"a CERTIFICATE OF LIABILITY INSURANCE 7/22/2014 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 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 Sheila Si ins NAME: gg Bell Anderson Agency, Inc. PHONE Extle (425)291-5200 A/C No;FAX (425)291-5100 600 SW 39th Street, Suite 200 E"MAIL .sheilas@bell-anderson.com INSURERS AFFORDING COVERAGE NAIC# Renton WA 98057 INSURERA:Underwriters At Lloyds, London INSURED INSURER B: Friendship Diversion Services, Inc. INSURER C: PO BOX 11215 INSURER D: INSURER E: Olympia WA 98508 INSURERF: COVERAGES CERTIFICATE NUMBER:CL1472203716 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. INSR TYPE OF INSURANCE ADDL VD POLICY NUMBER MM/DD/YYYY MM POLICY EFF POLICY EXP LTR /D/YYYY LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 11000,000 DAMA15TETO RENTED 100,000 % COMMERCIAL GENERAL LIABILITY PREMISES Ea occurrence $ A CLAIMS-MADE FxI OCCUR J1009714 /1/2014 /1/2015 MED EXP(Any one person) $ 1,000 X $5,000 Ded incl LAE PERSONAL&ADV INJURY $ 1.000.000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 2,000,000 JECT POLICY PRO- LOC $ A COMBINED SINGLE LIMIT AUTOMOBILE LIABILITY Ea accident ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS NON-OWNED PROPERTY DAMAGE $ HIRED AUTOS AUTOS Per accident UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED I I RETENTION$ $ WORKERS COMPENSATION WC STATU- OTH- AND EMPLOYERS'LIABILITY Y/N I TOR LIMITS ER ANY PROPRIETOR/PARTNER/EXECUTIVE❑ E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? N/A 12:00:00 :00:00 AM (Mandatory in NH) E1.DISEASE-EA EMPLOYE $ If yes,describe under DESCRIPTION OF OPERAT IONS below E.L.DISEASE-POLICY LIMIT $ A Criminal Justice Liablity CJ1009714 /1/2014 /1/2015 Limit $1,000,000 Deductible $5,0 0 0 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (Attach ACORD 101,Additional Remarks Schedule,if more space is required) City of Kent is additional insured for general liability, but only if required by written contract or written agreement per attached endorsement # CJ111 0109. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN City of Kent ACCORDANCE WITH THE POLICY PROVISIONS. Chief Prosecutor; City of Kent Law Dept AUTHORIZED REPRESENTATIVE 220 Fourth Avenue S Kent, WA 98032 _ James Hunt/SMA - ACORD 25(2010/05) ©1988-2010 ACORD CORPORATION. All rights reserved. INS025(201005).01 The ACORD name and logo are registered marks of ACORD LW k 1 0,21 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED -- DESIGNATED PERSON OR ORGANIZATION This endorsement modifies insurance provided under the following: i CRIMINAL JUSTICE SYSTEM OPERATIONS LIABILITY POLICY { SCHEDULE 1 Name Of Additional Insured Person(s)Or Organization(s): City of Port Townsend—City Attorney,250 Madison Street,Suite 92,Port Townsend,WA 98368 Clallam County Prosecuting Attorney,Attn:Deb Kelly, 223 E.0 St,Suite 11,Port Angeles,WA 98362 803 Executive,LLC,304 Island Aire Drive,Woodland,WA 98674 Mr.James Emacio,Chief Civil Deputy of Spokane, 1115 W.Broadway,Spokane,WA 99201 James McNamara,City of Longview City Attorney,1525 Broadway,Longview,WA 98632 City of Port Angeles,Attn:Heidi Greenwood,City Attomey, PO Box 1150,Port Angeles,WA 98362 Clallam County Jail Superintendent,Attn: Ron Sukert,223 E.4"St.,Suite 12,Port Angeles,WA 98362 Okanogan County Administrative Services;Attn:Nanette Kallunki, 123 5"Ave.,N,#106,Okanogan,WA 98840 j Grant County,Attn: Mr.D.Angus Lee,Prosecuting Attorney,PO Box 37,Ephrata,WA 98823 Thurston County,Attn:Jon Tunheim,County Prosecutor,2000 Lakeridge Dr.,Olympia,WA 98502 I City of Kent,Chief Prosecutor,City of Kent Law Dept.,220 Fourth Ave.,S,Kent,WA 98032 City of Sequim,Attn: Craig Ritchie,City Attorney, 152 W. Cedar St.,Sequim,WA 98381 Stephen Penner,Asst.Criminal Division Chief;Pierce County Prosecutor's Office; 946 County-City Building, Tacoma,WA 98402 Jefferson County Prosecutor,Jefferson County Courthouse,Attn: Scott Rosekrans, 1620 Jefferson, Port Townsend, WA 98366 Information required to complete this Schedule if not shown above,will be shown in the Declarations. SECTION II —WHO IS AN INSURED is amended to include as an additional insured the person(sy or organization(s)shown in the Schedule,but only with respect to liability caused,in whole or in part,by you or those acting on your behalf: 1. In the performance of your ongoing operations;or 2. In connection with your premises,owned by or rented to you. ALL OTHER TERMS AND CONDITIONS OF THE POLICY REMAIN UNCHANGED. I� CJ111-0109 Includes copyrighted material of Insurance Services Office, Inc. Page 1 of 1 with its permission. i