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HomeMy WebLinkAboutCAG2019-136 - Insurance Certificate - Education with Purpose Foundation for Pacific Islanders - Liability Coverage - 04/20/2020A� 0� CERTIFICATE 4F LIABILITY INSURANCE DATE (M71202YYYJ 1or2�12o20 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(les) must have ADDITIONAL INSURED provisions or 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 endorsements . PRODUCER Statefarm D JONES INS AND FIN SVCS INC • - ® 124 4TH AVE S STE 210 KENT WA 98032 CONTACT Norma Morales NAME: PHCN o Yt 253-850-3226 nlc Nn c 253-203-6029 E-MAIL norma.morales.xn5k@statefarm.com ADDRESS: INSURERS AFFORDING COVERAGE NAIC # INSURER A : State Farm Fire and Casualty Company 25143 INSURED EDUCATION WITH PURPOSE FOUNDATION 1615 W SMITH ST #A204 KENT, WA 98032-4305 INSURER B : INSURER C: INSURER D : INSURER E : INSURER F -A^nM r`11=17TICIr`ATC MI INIRFR• 5 REVISION NUMBER: D 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 LTR TYPE OF INSURANCE ADDL SUER POLICY NUMBER MMIDDIYYYY) (MMIDONYYYI LIMITS COMMERCIAL GENERAL LIABILITY CLAIMS -MADE ® OCCUR X 98CQP8042 04/20/2020 04/20/2021 EACH OCCURRENCE S 2,000,000 PREMISES -Ea occurrence S 1,000,000 MED EXP (Any one person) S 1 ❑,000 PERSONAL & ADV INJURY 3 1,000,000 GEN'LAGGREGATE LIMITAPPLIESPER: ❑ PRO- ❑ LOG POLICY JECT F9 OTHER: GENERAL AGGREGATE S 4,000,000 PRODUCTS-COMPIOPAGO $ 4,000,000 AUTOMOBILE LIABILITY ANY AUTO OWNED SCHEDULED AUTOS ONLY AUTOS HIRED NON -OWNED AUTOS ONLY AUTOS ONLY Ea acniCMBIdeDtSINGLE LIMIT S BODILY INJURY (Per person) S BODILY INJURY (Per accident) S PROPERTY DAMAGE Per accident S S UMBRELLA LIAB EXCESS LIAB OCCUR CLAIMS -MADE EACH OCCURRENCE $ H AGGREGATE S DED RETENTIONS $ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY YIN ANY PROPRIETORlPARTNERIEXECUTIVE ❑ OFFICERIMEMBER EXCLUDED? (Mandatory In NH) If yes, describe under DESCRIPTION OF OPERATIONS below NIA A PER, OTH- STUTE ER E.L. EACH ACCIDENT $ IPLOYEE 3 E.L. DISEASE -POLICY LIMIT $ DESCRIPTION OF OPERATIONS ! LOCATIONS ! VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached If more space Is required) rA klf=! I AT"AI VCR I Ir I+,+H I C f7VLu �n - --- SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Additional Insured:- ACCORDANCE WITH THE POLICY PROVISIONS. City of Kent Housing & Human AUTHORIZED REPRESENTATIVE 220 4th AVE S Kent, WA 98032 c ISif-C1T'l i]RI.VI'CU I.VR�V![Nllurv. nu nU11tA rcacrvcaa. ACORD 25 (2016103) The ACORD name and log are register; arks of ACORD 1001486 132849.12 03-16-2016 CMP-4860 Page 1 of 1 CMP-4860 ADDITIONAL INSURED DESIGNATED PERSON OR ORGANIZATION THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY CG Policy No.98 CQP804 2 194B-FACD This endorsement modifies insurance provided under the following: BUSINESSOWNERS COVERAGE FORM SCHEDULE Policy Number: Named Insured: 98 CQP804 2 EDUCATION WITH PURPOSE FOR PACIFIC ISLANDERS (NON PROFIT) 1615 W SMITH ST APT A204 KENT WA 98032-4305 1. SECTION II WHO IS AN INSURED of SECTION II 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. Premises And Ongoing Operations Your acts or omissions or the acts or omissions of those acting on your behalf: (1) In connection with your premises; or (2) In 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 Insurance. The insurance afforded the additional insured shall be primary insurance. Any insurance carried by the additional insured shall be noncontributory with respect 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. Name And Address Of Additional Insured Person Or Organization: CITY OF KENT HOUSING & HUMAN SERVICES 220 4TH AVE S KENT WA 98032 5838 © , Copyright, State Farm Mutual Automobile Insurance Company, 2008 Includes copyrighted material of Insurance Services Office, Inc., with its permission. CMP-4860 1006243 137750.2 01-30-2019 Name And Address Of Person Or Organization: CITY OF KENT HOUSING & HUMAN SERVICES 220 4TH AVE S KENT WA 98032 5838 The following is added to Paragraph 10.b. of SECTION I AND SECTION II COMMON POLICY CONDITIONS: We waive any right of recovery we may have against the person or organization shown in the Schedule because of payments we make for injury or damage arising 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. 1006225 137715.1 11-19-2013 CMP-4787 Page 1 of 1 CMP-4787 CMP-4787 WAIVER OF TRANSFER OF RIGHTS OR RECOVERY AGAINST OTHERS TO US THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY CG Policy No.98 CQP804 2 This endorsement modifies insurance provided under the following: BUSINESSOWNERS COVERAGE FORM SCHEDULE Policy Number: Named Insured: EDUCATION WITH PURPOSE FOR PACIFIC ISLANDERS (NON PROFIT) 1615 W SMITH ST APT A204 KENT WA 98032-4305 , Copyright, State Farm Mutual Automobile Insurance Company, 2008 Includes copyrighted material of Insurance Services Office, Inc., with its permission. © 98 CQP804 2 &. ffifr StateFarm Office Policy STATE FABM FIRE AND CASUALTY COMPANY A STICK CeMpANywtTH HaME oFFrcES tN BLooMrNGToN, tLLtNors HENEWAL DECLARATIONS E?"F ?id*fr : ?* 7 s o I s - s s z s Addl Insured-Section ll Only Arz 001215 312SM-15-6079-FACD F U CITY OF KENT HOUSING & HUI'IAN SERVICES220 4TH AVE S KENT t'lA 98052-5858 ll,llllllllllrlllh;rrllllll1111l1,,;rh;ll,,lh1;rrll'l'l,ll'l Policy ltlumber 98-CQ-P8O4-2 Policv Pedod Eflecliue Date Exoiration Date 12 Mbnths APR 20 2020 APR 20 2021 The polipy period begins and ends at12:0i am standard flme atthe premtses Tocaflon. Named lnsured EDUCATION WITH PURPOSE FOR PACIFIC ISLANI'ERS(NON PROFIT) 1615 tll SI'IITH ST APT A2O4 KENT l'A 98032-430soooia6o Automatic Rsnewal - lf the policy period i forms in effectfor each succeeding policy compliance widr the policy provisions or a s shown as 12 months , this policy will be renewed automatcally subjectto the premiums, rules and period. lf this policy is terminated, we will give you and the Mortgageei Lienholder written notice in s required by law. Entity:NON PROFIT NOTICE; lnformation concerning changes in your policy language is included. Please call your agent if you have any questions. POLICY PREMIUM Minimum Premium Discounts Applied: Years in Business Protective Devices $ 325.00 Prepared FEB 25 2020 cMP-4000 007950 294 At N @ Copyright, State Farm Mutual Automobile lnsurance Company,2008 lncludes copytighted material of lnsurance Ssrvices 0ffice, lnc.. with its permission, Continued on Reverse Side of Page Page 1 of 7 530-6860.2 05-31'2011 lo1t323lc) I REN EWAL DECLARATIONS (CONTINU ED) Olfice Policv for CITY OF KENT HOUSING & HUMAN Policy Num6er 98-CQ-P804-2 SECTION I. PROP RTY SEHEDTILE Locatlon Number Location of Described Premises Limit of lnsurance* Coveraoe A - Buildings Limit of lnsuranco* Coveraoe B - Business Fersonal Property Seasonal Increase- Business Personal Property 001 1615 W SMITH ST APT A2O4 KENT WA 98032-4305 No Coverage $ 26,000 25Yo *As spo nsurance as n any ue to on SECTION I.INFLATION COVERAGE INDEX(ES) - , . Cov A - lnflation Coverage lndex: Cov B - Consumer Price lndex: N/A 258.0 SFCTION I - DEDIIETIBLES Basic Deductible Speclal Deductlbles: Money and Securities Equipment Breakdown $'1,000 $250 $1,000 Employee Dishonesty $250 Other deductibles may apply - refer to policy Prepared FEB 25 2020 cMP-4000 007950 @ Copyrighf $tate FarmMutualAutomobils lnsurance Company, 2008 lnoludes copyrighted matsrial of lnsuronce Services Office, lnc,, with its petmission, Continued on Next Page Page 2ot 7 StateFarm&.RENEWAL DECLARATTONS (CONTTNUED) Office Po|icv for CITY OF KENT HOUSING & HUMAN Policy Number 98-CO-P804-2 ffiE SFCTION I- FXTFNSIONS Ntr COVEFIAGF. LIMIT OF INSIIRAN(]F - FA(]H NtrR(1FIIRtrN PREMISFS n 3 3 ltt".cov.erages and corresponding limits shown below apply separately to each described premises shown in thesek Peclarations, unlq99 indicated by "See Schedule." lf a cotrirag6 does hot have a correspohding limit shown below,p but has "lncluded" indicated, please refer to thal policy provislon for an explanation of that coverage. COVERAGE Accounts Receivable On Premises Off Premises Arson Reward Back-Up Of Sewer Or Drain Collapse Damage To Non-Owned Buildings From Theft, Burglary Or Robbery Debris Removal Equipment Breakdown Fire Department Service Charge Fire Extinguisher Systems Recharge Expense Forgery Or Alteration Glass Expenses lncreased Cost Of Construction And Demolition Costs (applies only when buildings are insured on a replacement cost basis) Money And Securities (Off Premises) Money And Securities (On Premises) Money Orders And Counterfeit Money Newly Acqrrired Business Personal Property (applies only if this policy provides Coverage B - Business Personal Property) Newly Acquired Or Constructed Buildings (applies only if this policy provides Coverage A - Buildings) LIMIT OF INSURANCE $s $t $5,ooo $10,000 $1,ooo $100,000 $250,000 0 5 0 0 ,00 ,00 $5,ooo $15,000 lncluded Coverage B Limit 25% of covered loss lncluded $5,ooo $5,000 $10,000 lncluded 10o/" Prepared FEB 25 2020 cMP-4000 007951 294 N @ Copyright, State Farm Mutual Automobile lnsurance Company,2008 lncludes copyrighted material of lnsurqnce Services 0ffice, lnc., with its permission. Continued on Reverse Side of Page Page 3 of 7 REN EWAL DECLARATIoNS (CONTINUED) OIIice PoIIcv |or CITY OF KENT HOUSING & HUMAN Policy Num6er 98-CO-P804-2 Ordinance Or Law - Equipment Coverage Outdoor Property Personal Effects (applies only to those premises provided Coverage B - Business Personal Property) Personal Property Off Premises Pollutant Clean Up And Removal Preservation Of Property Property Of Others (applies only to those premises provided Coverage B - Business Personal Property) Signs Unauthorized Business Card Use Valuable Papers And Records On Premises Off Premises Water Damage, Other Liquids, Powder Or Molten Material Damage lncluded $5,ooo $5,000 $15,000 $10,000 30 Days $2,500 $2,500 $s,ooo $50,000 $15,000 lncluded SFETION I - FXTENSIONS OF EOVFRAGF .I IMIT OF INSIIPANCE. PER POLICY The coverages and corresponding limits shown below are the most we will pay regardless ol the number of described premlses shown in these Declarations. COVERAGE Dependent Property - Loss Of lncome Employee Dishonesty Utility lnterruption - Loss Of lncome Loss Of lncome And Extra Expense @ Copyright, State Farm Mutual Automobile lnsurance Compnny,2008 lncludes copyrighted material of lnsurance Services 0ffice, lno., with its permission, Continued on Next Page LIMIT OF INSURANCE $5,000 $10,000 $10,000 Actual Loss Sustained - 12 Months Prepared FEB 25 2020 cMP-4000 00795 1 Page 4 ol 7 StateFarm&,RENEWAL DECLARATTONS (CONTTNUED) Office Policv for CITY OF KENT HOUSING & HUMANPolicy Number 98-CQ-P804-2 ffi SECTION II.I IABII ITV I oo * @do a COVERAGE Coverage L - Business Liability Coverage M - Medical Expenses (Any One Person) Damage To Premises Rented To You AGGREGATE LIMITS Products/Completed Operations Aggregate General Aggregate LIMIT OF IN$URANCE $2,000,000 $10,000 $1,000,000 LIMIT OF INSURANCE $4,000,000 $4,000,000 Each paid claim for Liability Co,verage reduces the amount of insurance we provide during the applicable annual period. Please refer to Section ll - Liability in the Coverage Form and any attached endoidements, Your policy consists of these Declarations, the BUSINESSOWNERS COVERAGE FORM shown below, and any other lorms and endorsements that apply, including those shown below as well as those issued subsequent to the issuance of this policy. FrlRME ANN trN RSFMFNTS cMP-4102 FE-6999.2 cMP-4819.1 cMP-4247.1 FE-3650 cMP-4572 cMP-4561.1 cMP-47A5.2 cMP-4710 cMP-4709 cMP-4706 cMP-4704.1 cMP-4703.1 Businessowners Coverage Form*Terrorism lnsurance Cov Notice Unauthorized Business Card Use Amendatory Endorsement Actual Cash Value Endorsemet Amendment of Premium Cond Policy Endorsement Loss of lncome & Extra Expnse Employee Dishonesty Money and Securities Back-Up of Sewer or Drain Dependent Prop Loss of lncome Utility lnterruption Loss lncm Prepared FEB 25 2020 cMP-4000 007952 294 N @ Copyright State Form Mutual Automobile lnsuranoe Company,2008 lncludes copyrighted material of lnsuronce Services Office. lnc., with its permission Continued on Reverse Side of Page Page 5 of 7 RENEWAL DECLARATION$ (CONTINU ED) OIIIce PoIIcv |or CITY OF KENT HOUSING & HUMAN Policy Num6er 98-CQ-P804.2 cMP-4788 cMP-4860 cMP-4787 FD-6007 Addl lnsd Mgrs Lessor of Prem Al Design Person Org Waiver of Trans Rgt of Recov lnland Marine Attach Dec * New Form Attached This policy is issued by the $tate Farm Fire and Casualty Company, Participating Policy You are entitled to participate in a distribution of the earnlngs of the company as determined by our Board of Directors in accordance with the Company's Articles of lncorporation, as amended. Fire and Casualty Company has caused this policy to be signed by its President and tA,.u{tf> President Prepared FEB 25 2020 cMP-4000 o07952 @ Copyright, State Farm Mutual Aulomobile lnsurance Company,2008 lncludes copyrighted material of lnsurance Services 0ffioe. lnc,, with its permission. Continued on Next Page Page 6 of 7 ' stateFarm&,RENEWAL DECLARATTONS (CONTTNUED) Office Po|icv for CITY OF KENT HOUSING & HUMAN Policy Number 98-CQ-P804-2 ffit oa + @do* NOTICE TO POLICYHOLDER: For a comprehensive description of coverages and forms, please refer to your policy. Policy changes requested before the "Date Prepared", which appear on this notice, are eifective on the Renewal Date of this policy unless otheruise indicated by a separate endorsement, binder, or amended declarations. Any coverage forrns attached to this notice are also effective on the Renewal Date of this policy. Policy changes requested after the "Date Prepared" will be sent to you as an arnended declarations or as an endorsement to your policy. Billing for any additional premium tor such changes will be mailed at a later date. lf, during the past year, you've acquired any valuable property items, made any improvements to insured property, or have any questions about your insurance coverage, contact your State Farm agent. Please keep this with your policy, Prepared FEB 25 202A cMP-4000 007953 294 N @ Copyright. State Farm Mutual Automobile lnsurance Company,2008 Includes copyrighted material of lnsurance Services Office, lnc., with its permission Page 7 o'f 7 98-CO-P804-2 007953 StateFarm STATE FARM FIHE AND CASUALTY COMPANY A srocK CoMpANywtrH HIME oFFrcEs tN BLIIMINGTON, tLLtNotS INLAND MARINE ATTACHING DECLAHATIONS&. E?,8 ?fdgTfr : lfr 7 s o B s. 3 s 2 s Named lnsured EDUCATION WITH PURPOSE FOR PACIFIC ISLANDERS(NON PROFIT) 1615 W SI'IITH ST APT A2O4 KENT l,lA 98052-4505 Policy Nurnber 98-CQ-P804-2 Policv Pedod Ellective Dalo Exnintion Date 12 Mbnths APR 20 2020 APR 20 2021 The polipV period begins and ends at 12:01 am standard tme atme premlses locauon. M-15-6079-FACD F U ffifi oooo +ado o ATTACHING INLAND MARINE Automalic Renewal - lf the policy pedod is shown as 12 months , this policy will be renewed automatically subjectto the premiums, rules and forms in effect for each succeeding policy period. lf this policy is terminated, we will give you and the Mortgagee/Lienholder written notice in compliance widr the policy provision$ or as required by law. Annual Policy Premium lncluded The above Premium Amount is included in the Policy Premium shown on the Declarations Your policy consists of these Declarations, fte INLAND MARINE CONDITI0NS shown below, and any other forms and endorsements that apply, including drose shown below as well as those issued subsequentto the issuance of this policy. Folms, 0ptions, and Endorsements FE-8724 FE-8744.1 lnland Marine Conditions lnland Marine Computer Prop $ee Reverse for Schedule Page witr Limits Prepared rEB 25 2020 FD-6007 007954 @ Copyrigh! State Farm Mutual Automobile lnsurance Company,2008 lncludes copyrighted material of lnsurance Services 0ffice, lnc., with its permission 530'686 a.2 05.$1"201 I {olf3212cl 98-CQ-P804-2 ATTAC HING II{LAND MARINE ATTACHING IN[A]'ID MABIilE SCHEDUIE PAGE ENDORSEMENT NUMBER FE-8744.1 COVERAGE lnland Marine Computer Prop Loss of lncome and Extra Expense LIMIT OF INSUHANCE DEDUCTIBLE AMOUNT $ 500 ANNUAL PREMIUM Included Included I $ 25r000 25r000 Prepared FEB 25 2020 FD-6007 007954 OTHEB LIMITS AND EXCLUSIONS MAY APPLY . REFER TO YOUR POLICY @ Copyrigh[ Stote Farrn Mutual Automobile lnsurancs Company.2008 lnoludes copyrighted material of lnsu;'once $ervices 0ftioe. lnc., with its permission. 530'086 a.2 05'31-?011 (olf3233c)