HomeMy WebLinkAboutCAG2023-131 - Insurance Certificate - Afghan Health Initiatives - Liability Coverage - 03/09/2023 A�" CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDDIYYYY)
08/14/2023
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 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 endorsement(s).
PRODUCER CONTACT DougJones
NAME:
StateFarm Doug Jones A/CC,No Ext: 253 850 3226 a/c No):
0 124 4th Ave S Suite 210 E-M RESS: doug.jones.srat@statefarm.com
INSURER(S)AFFORDING COVERAGE NAIC#
Kent WA 980325821 INSURER A: State Farm Fire and Casualty Company 25143
INSURED INSURER B: State Farm Mutual Automobile Insurance Company 25178
AFGHAN HEALTH INITIATIVE INSURERC:
30607 134TH AVE SE INSURER D:
INSURER E:
AUBURN WA 980922248 INSURERF:
COVERAGES CERTIFICATE NUMBER: 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 ADD SUB POLICY EFF POLICY EXP
LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER MM/DD/YYYY MMIDD/YYYY LIMITS
X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000
TED
CLAIMS-MADE � OCCUR PREMISES
(E.occurrence)
DAMAGE TO lccurrrence) $ 300,000
MED EXP(Any one person) $ 5,000
A Y Y 98-C6-X178-9 06/01/2023 06/01/2024 PERSONAL&ADV INJURY $ 1,000,000
GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000
PRO-
POLICY JECTPRO- X LOC PRODUCTS-COMP/OP AGG $ 2,000,000
OTHER: $
AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT
508 0213-A24-47 07/24/2023 01/24/2024 Ea accident $
ANY AUTO BODILY INJURY(Per person) $ 1,000,000
B OWNED �/ SCHEDULED N N 4766339-009-47A 03/09/2023 09/09/2023 BODILY INJURY Per accident 1,000,000
AUTOS ONLY /� AUTOS ( ) $
HIRED NON-OWNED
AUTOS ONLY AUTOS ONLY Per accident $ 1,000,000
UMBRELLA LIAB OCCUR EACH OCCURRENCE $
EXCESS LIAB CLAIMS-MADE AGGREGATE $
DED RETENTION $ $
WORKERS COMPENSATION PER OTH-
AND EMPLOYERS'LIABILITY ISTATUTE ER $
ANY PROPRIETOR/PARTNER/EXECUTIVE Y/N
OFFICER/MEMBER EXCLUDED? ❑ N/A E.L.EACH ACCIDENT $
(Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $
If yes,describe under
DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $
DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required)
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-PARKS RECREATION&COMMUNITY SERVIC ACCORDANCE WITH THE POLICY PROVISIONS.
425 4TH AVE N
AUTHORIZED REPRESENTATIVE
KENT WA 98032s�— This form was system-generated on 08/14/2023
@ 1988-2015 ACORD CORPORATION. All rights reserved.
ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD
1001486 2005 155279 205 01-19-2023