HomeMy WebLinkAboutCAG2019-136 - Insurance Certificate - Education with Purpose Foundation for Pacific Islanders - Liability Coverage - 04/20/2018RFT4Exchange 6/6/ZOL9 11:49:29 AM pAcE 3/OOS Fax Server
CERTIFICATE OF LIABII.ITY INSURANCE DATE IIilM'DD/YYYY}
06i05i2c 1 s
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY ANO CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED By THE pOLtCtE9
BELOW. THIS CERTIFICATE OF TNSURANCE DOES NOT CONSTTTUTE A CONTRACT EETWEEN THE ISSU|NG TNSURER(S), AUTHORTZED
R,EPRESENTATIVE OR P AND THE CERTIFICATE HOLSER.
IMFORTANT: lf the certiflcate holder is an ADDITIONAL INSURED, the policy(ies) must have ADDITIONAI, INSURED provislons or be endorsed.
lf SUBROGATI9N 15 WAIVED, subject to the tetms and conditions of the policy, certain policies may require an endolsement. A statement on
this certlficate does not confer rights to the certificate holder in lieu of such endorsement{s).
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ill:n|F",,". 253.850.322s 253-203.6029FAX
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UGIN$UiiE.S M[.COtIJJAIJt
INSURERfSI AFFORT}ING CO\/ERAGF NAIC #
D JONSS; INS AND FIN SVCS INC
124 4l-ti AVL, S S'iL 210
KENT i^iA gEC32
PRODUCER
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tNslrRER A . Siate i:arm Fii'e an(i Casuairy Ccmpan'y'25143
ITISURER B
INSURER C :
INSURER O :
INSURER E:
EDUCA.-IION'vVlTH PUR pO$E FOU NDAl-lOl'j
1615 \IJSI\4|'iH ST #A204
KENI, WA.98C32,43C5
INSt'RED
I'.ISURER F :
COVERAGFS REVISION NUMBER:5
THIS i$ TO CFRTIF/ THAT THE POI.ICIFS OF IN$'-IRANCE I.ISIED BET.O\^/ HAVE REFN ISSTJED TO THE II'..ISURFD NA}JED AEJCVE FOR THE PCI-ICY PERI()D
INIDICATED. NCTIVITHSTAIIDING ANY REOUIREMENT, TERT/ CR CCNDITION CF AI{'T CONTRACT OR CTHER DCCUUIENT WITH RESPECT TC WHICH IHIS
CERTIFICATE I',IAY BE ISSUED OR IV1AY PERTAIN, THE IIISURANCE AFFORDED BY THE PCI-.ICIES DESCRIBED HEREIN IS SLTRJEOT TO AI"-1. THE TERMS,
EXCLUSIONS ANID CCf{DITICNS OF SUCH POLICIES. LllvilTS SHOWN lviAY HAVE BEEN REDUCED BY PAID CLAIM$.
IN9R TYFE OF INSURANCE POI ICY NIIMRFP FgLIGY EFF(nnldmntvwvt POLICY EXPtitltrnhrvvvvr LIMIYS
EACi-! OCCURRENCI:$ 2,000,000
$ 1,000,000
IviED EXP iAPv cns oerscnl $ 10,c00
FERSOi\iAi- & Af)V iNi.jPY $ 1,000,c00
CJEhI ERAT. A'JTJ REGATE $ 4,000,000
Pi?oDr.icis - cotJlP/oir A.GG s 4.000,C00
COM}.,IERCIAL GEN ERAL I.IABILIf Y
cLArMs-MADs X o""ro
PER
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APPI.IF$IPRC)"
.JECT
X SricQts3042 04-20 2C18 c4-20-2C20
$
$
BCDiL.Y ill..luRY iPer person)$
BODIi-Y INiURY (l5er arcident)$
s
AUTOTIJEBILE LIABILITY
AilY A.UiO
CVVNED
A(.JTOS CrNt.Y
iriFtEI)
AU]-OS ON|_Y
SCI-JEDLJLED
AUTOS
NIC)li-OrrVl.i-trt
Ar.iios oNrY
FA$|-] OCCURRENCE $
€XCESS I.I,AB
occ!.iR
Ci AiMS.rv!AD=ACJCJRCCTATE !l;
i?FTtrNTIi]N S
OTFI.trR
E.i_ EACI] ACCiDeNT $
E.L DISEASE . EA E|VII)I OYEF $
WORKERS COMPENSATIOII
AND EMPLOYERS' LI.AgILITY
lii\i Y pil opit i= ioR lirAR.- N F. R/EXF:cr.i I r vF:
OFF i OERi N{EI.4 BER EXCLTJDEI-T?
(Mandaldryan NH)
lfyes, desclibe uncler
ntrSaR ip?lr-tN ar onF:RAilo\ls brlA\d
fr N/A
E L DISEA.SE . POLICY LILI|T
OESCRIPTIONOFOFERATIONS/LOCATIONS/VEHICLES IACORD'lOl,AddilionalRemarksSchedula,rnqybe?llRclredifmoraspacsisreqsirad)
cllY oir KEN-| l-ioustN(i & ilrit'"lAN..i sERvtcrs
220 4TiI AVE S
KEI\]", \n A 9i1032-5ii3il
EDUC/\ilol\i \r'lfli-l PURPCSE F:OLjf..rDATlON 615 W SlJlTi-l Sl #A2C4 Ki:i.t'i, \r,/A 96032-4305
TION
5 ACORD CORPORATION. All rights reserved.
SHOULD ANY OF THE ABOVE DEAGRIAES POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE W|LL BE DELIVEREP IN
ACCORDANGE WITH THE POLICY PROVISIONS.CIIY OF. Ktr_Ni HOUS|NG & HUTVIAN SERVICES
220 4-IH AVE S
KENT. WA 98032.5838 AUTHORIZ ED
ACORD 25 (2016103)The ACORD name and logo are registered
o
ks of ACORD
1001.180 132849.12 03-16.2C10
RFT4Exchange 6/6/ 2019 ll:49:29 AM PAGE 4/OOS Fax Server
Policy No. lr8-rlij-P804-Z {1;0'1 9-F.\cD
T}iI8 ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY
GMP486O ADDITIONAL II\ISURED - DESIGNATED FER$ON OR ORGANIZATIOT{
CMP 4360
Page 1 cf 1
This endorsement modifies insurance provided under the following
BUSINESSOWN ERS COVERAGE FORM
SCHEDULE
Policy Number: 98-cQ-P804-2
Named lnsured:
Fii)iiCATf Ol.l inil?Li PURFOSE FOP. FACTFIC ISI,A\IDERS
1.6i-i; tf "'ii.'liTlii ii1' APTI A20'i
KEi.iT, t'$-A !lUO-12*4 :lO:)
(NCN PROFIT)
Narne And Address Of Additional lnsured Person Or Organization
CJ.TTY CF KN}IT I.iCIJSI}.IG f. I{IJI"TIAI\T SERVICES
2.2.O 4Tr{ ,riviji :1
KEI'IT, i'iA 98032-53:-rg
1. SECTION ll - WHO lS AN INSURED of SEGTION ll - LIABILITY is amended to include, as an
additional insured, any person or organization shown in the Schedule, but only with respect to liability
for "bodily injury", "property damage" or "personal and advertising injury" caused, in whole or in part,
by:
a. Prernises And Ongoing Qperations
Your acts or omissions or the acts or omissions of those acting on your behalf:
(1) ln connection with your premises; or
(2) ln the performance of your ongoing operations; or
b. Products-Completed Operations
"Your work" performed for that additional insured and included in the "products-completed opera-
tions hazard".
2. Any insurance provided to the additional insured shall only apply with respect to a claim made or a
"suit" brought for damages for which you are provided coverage.
3. Primary lnsurance. The insurance afforded the additional insured shall be primary insurance. Any
insurance carried by the additional insured shall be noncontributory with respec* to coverage pro-
vided by you.
There will be no refund of premium in the event this endorsement is cancelled.
All other policy provisions apply.
€r. Copyright, State Far,'n Muiuai A.uiomobile lnsurance Cornpany, 200€i 100ti243 13/75!J.2 C1-30 2C19
lnciudes ccpyi'ignie(i rnatei'iai cf lnsuiance Senrices Offioe, lilc., with iis peirnissioit.
cl\JItr.4860
RFT4Exchange 6/8/2013 11:49:29 AM PAGE S/OOS Fax Server
Policy No. 9t-?-i(l-iii-r01-{-2 (1;0't g-FACD
TIiIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY
CMP4787 WAIVER OF TRANSFER OF RIGHTS OR RECCIVERY AGAIN.ST
OTHERS TCI US
G.t ctvtir..47B7
Page 1 cf 1
This endorsement modifies insurance provided under the foilowing:
BUSINESSOVVN ERS COVERAGE FORM
SCHEDUI.E
Policy hlumber: 9il-rle-FB o4*2
Named lnsured:
EDUCA:t'1Ci'i WiTiI FUiii-'OSE F'OF. PA']rF'IC IS]iAI.IDE11S
].61jJ i^J Si":IITFi .ST APT A2O4
KEIIT / WA !180:i2-4:105
Narne Ancl Address Of Person Or Organization
C]TY CF TiENT T{OUS]IJG 5I iii]i"lAN SERVICES
2.'2i) ri:1'!i A\".'t_L 5
KEiiT, I',iA 98C-12-:ji].i8
(i\iol'l iriiol-i T )
IIle- t9!19*lng is added to Paragraph 10.b. of SEGTIoN I AND SEGT|ON il - cOMMoN po|.tcy
CONDIT!QNS:
We waive any right of recovery y/e may have against the person or organization shown in the Schedulebecause of payments we make for injuiy or damage arisirig out of:
a" Your ongoing operations; or
b. "Your work" done under contract with that person or organization and included in the "products-completed operations hazard".
This waiver applies only to the person or organization shown in the Schedule.
All other policy provisions apply.
cMP-4787
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1377151 1''-1e-2c13