Loading...
HomeMy WebLinkAbout18513 59th Ave Ne_BLD6408_2025 CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DD/YYYY) 1/15/2025 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). CONTACT PRODUCER NAME: Acrisure Great Lakes Partners Insurance Services PHONE FAX 223 West Grand River Ave #1 (A/C, No, Ext): 216-658-7100 (A/C, No):216-658-7101 E-MAIL Howell MI 48843 ADDRESS: INSURER(S) AFFORDING COVERAGE NAIC # INSURER A : Everest Indemnity Insurance Company 10851 INSURED 18234 Everest Denali Insurance Company 16044 INSURER B : Western Display Fireworks Ltd. INSURER C : AXIS Specialty Insurance Company 15610 P. O. Box 932 Canby OR 97013 INSURER D : Chesapeake Employers Insurance Company 11039 INSURER E : INSURER F : COVERAGES CERTIFICATE NUMBER: 1772646583 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 ADDLSUBR POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSR WVD POLICY NUMBER (MM/DD/YYYY) (MM/DD/YYYY) LIMITS A GENERAL LIABILITY GCI0010117-251 1/15/2025 1/15/2026 EACH OCCURRENCE $1,000,000 X DAMAGE TO RENTED COMMERCIAL GENERAL LIABILITY PREMISES (Ea occurrence) $500,000 CLAIMS-MADE X OCCUR MED EXP (Any one person) $ PERSONAL & ADV INJURY $1,000,000 GENERAL AGGREGATE $2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP/OP AGG $2,000,000 X POLICY X PRO-JECT LOC $ B AUTOMOBILE LIABILITY GCD0010050-251 1/15/2025 1/15/2026 COMBINED SINGLE LIMIT (Ea accident) $1,000,000 X ANY AUTO BODILY INJURY (Per person) $ ALL OWNED SCHEDULED BODILY INJURY (Per accident) $ AUTOS AUTOS NON-OWNED PROPERTY DAMAGE X HIRED AUTOS X AUTOS (Per accident) $ $ C UMBRELLA LIAB X OCCUR P-001-000069176-07 1/15/2025 1/15/2026 EACH OCCURRENCE $4,000,000 X EXCESS LIAB CLAIMS-MADE AGGREGATE $4,000,000 DED RETENTION$ $ D WORKERS COMPENSATION 8025102 1/15/2025 1/15/2026 X WC STATU- OTH- AND EMPLOYERS' LIABILITY TORY LIMITS ER Y / N ANY PROPRIETOR/PARTNER/EXECUTIVE E.L. EACH ACCIDENT $1,000,000 OFFICER/MEMBER EXCLUDED? N / A (Mandatory in NH) E.L. DISEASE - EA EMPLOYEE $1,000,000 If yes, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT $1,000,000 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required) Additional Insured extension of coverage is provided by above referenced General Liability policy where required by written agreement. Display Date: 7/4/25 Display Site: Quake Park, 18501 59th Ave NE, Arlington, WA 98223 Additional Insured: The City of Arlington, it's officers, agents and employees Arlington Fire Dept. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. City of Arlington 238 N Olympic Ave Arlington WA 98223 AUTHORIZED REPRESENTATIVE © 1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25 (2010/05) The ACORD name and logo are registered marks of ACORD Exhibit A—Display Site Map—Arlington N 300’ Fall Out Area Fall Out Area 330’ 350’ Discharge Site 20’x10’ Fall Out Area Fall Out Area 310’ Western Display Fireworks LTD. Bill Quake Memorial Park—Arlington, WA Discharge Site 20’x10’ 48° 9'56.05"N 122° 8'58.36"W Spectators UPDATED 10/16/2024       !"#$ %&'()*+(,%+(*'-%./01,'%-2+%31.'14&/0 56#7$ 8-1*-%(.'14&/0,'%-2+%31 56#7599:: ;<= 56#7>?>@>A B/(C0DD=E  ?!7# .-F'(+44-( G!7    === H6 I-F'(J2-1*-%(I'14&/0KL+M @#!!NO!P /-%'/&Q'%-2+%3I'14&/0 R6S!7 K @TSU $SV!N@!: ?!7:S#!7 W##S7#X!S Y?!9 Y::S9 =  HZ: E   U!  @S: B[\ 5::]79! ^/((/_^/%I2'L3 ! /%L-&` II%-11\-)/&.-1L%'4*'+(2(-%/M- 2(-%_+(- a+('() cB8  \ Bd =            !" #$%&'( ) *+,) *,-.,/+,/- 0 1 21  3-45,) 6 7 8 29:;:<=  >+* ?@ 1 21  9  7 8 29 AB('CD'EF'G&   HIC&CJD&( ) K5L- 1 21  MNOPNQRSTMOMUVWXYNROZV[\\]^_`^abcdef_g 71 h1  MRQOZiNZTMOMUOiPRVWXYNROZVjk[ef_g 71 h1  MRQOZiNQTMOMUOiPRVWXYNROZVlca^mnao\p^qrscqctseufv 71 h1  MRQOZiSOTMOMUOiPRVWXYNROZVwxy^s^atzYc\fzt{Xcq^s\^MOMUef_g 71 h1  |}~€‚|ƒ||„ }†‡ˆ‰Š}€†‹ŒŒŒŽ 71 h1  MRQOZiSiTMOMUOiPRVWXYNROZVcd^`ztsef_g 71 h1  MRQOZiSRTMOMUOiPRVWXYNROZVwtdtd^`^abcdxffef_g