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CONSO-1 OP ID: DB
<br /> CERTIFICATE OF LIABILITY INSURANCE
<br /> DATE 09/10D1YYYY)
<br /> CERTIFICATE Vr 091'10195
<br /> THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER, THIS
<br /> CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
<br /> BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED
<br /> REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER.
<br /> IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed, If SUBROGATION IS WAIVED, subject to
<br /> the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the
<br /> certificate holder in lieu of such endorsement(s),
<br /> PRODUCER 360-748-0051 cNAME INTACT Debbie Buss _
<br /> Virgil R.Lee&Son _ _.
<br /> Lovsted Worthington LLC 360-748-3941HaNN�E�;380-748-0t}5I _ - No#:360-748-3941
<br /> P.O.Box 9226 A'0DRESs:dbuss@lovstedworthinqton.com
<br /> Chehalis,WA 98532 - -
<br /> Trevor J Elliott ---- INSt1RER(SLAFFORDtNG caVERAGE. E_ NAIC a
<br /> iNSURERA:Berk�Assurance Company
<br /> INSURED Console Cleaning INSURER p,American Fire&Casualty„ - __.__123507_
<br /> Specialists,Inc. INSURERC:Torus S ecial Ins Co.
<br /> 1595 Bishop Rd ------ _.�_. �!
<br /> Chehalis,WA 98532 _ENSURER D: —
<br /> INSURE=R 6
<br /> INSURER F
<br /> COVERAGES CERTIFICATE NUMBER: REVISION NUMBER:
<br /> THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
<br /> INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
<br /> CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,
<br /> EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
<br /> ' POLICY EFF
<br /> LTR TYPE OF INSURANCE I Pot-ICY NUMBER i MMlDL11YYYY i MMlDDlYYYY E LIMITS
<br /> GENERAL LIABILITY i E '
<br /> EACH OCCURRENCE $ 1,000,00
<br /> E bAnnA �T�RLN I LU _
<br /> A X�cnM1 RCIAL GENERAL LIABILITY X X i iVt3NIBD063151 06120/15 i 06120/16 f PREMISES(Wa arcurrencel s 100,00
<br /> CLAIMS-MADE ( X OCCUR I I I ME P(Any one person) 5 EXC
<br /> X $2500 Ded BI/PD E ; F I j--------.____ _
<br /> W.� .. e j ; PERSONAL&ADV INJURY ; s 1,000,000
<br /> GENERAL AGGREGATE_._.._1 ____._.._._...2,000,00
<br /> GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS.COMPIOP AGG 1 $ 2,000,00
<br /> �>
<br /> i X POLICY L^ PRO- € LOC ii _._..____._-------
<br /> _.
<br /> I
<br /> i
<br /> AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT i
<br /> Ea accident 1,000,00
<br /> ANY AUTO X X ifiAA56199907 06120115 061201160DILY INJURY{Per person} ;$
<br /> ALL OWNED SCHEDULED
<br /> i AUTOS X l AUTOS I i I I BOOJLY INJURY(Per accident)t$
<br /> NOWOWNEp �PROPEF2TYDAMAGE
<br /> HIRED AUTOS AUTOS S
<br /> Por acc€dsnt
<br /> I __.._�
<br /> I I
<br /> UMBRELLA LIAR i I OCCUR i EACH OCCURRENCE $ 2,000,00
<br /> ' EXCESStEAB � CLAIMS � �85620JI51AL.1 06120115 1 06/20/96 i AGGREGATE $ 7,
<br /> X �_. _. __._. I AGGREGATE 000,00
<br /> 1 DED 1 RETENTION$
<br /> WORKERS COMPENSATION I I [ WG STATU- 10TH•;
<br /> AND EMPLOYERS'LIABILITY I j I I_,_..,1.TER
<br /> A i ANY PROPRIETORIPARTNERIEXECUTIVE YIN I i VUMB0063151 06/20/15 ! 01/20115 _E.L.EACH ACCIDEN T_ '$ 1,000,00
<br /> nFFICERlMEMBER EXCLUDED? ;N!A I
<br /> (Mandatory in NH) (WA STOP GAP) E.L.DISEASE-EA EMPLOYEEi S 1,000,00
<br /> IF yes,desuit-e under F j I
<br /> E DESCRIPTION OF OPERATIONS below I E L.DISEASE-POLICY LIMIT $— 1,000,00
<br /> I i i
<br /> DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101,Additional Remarks Schedule,if more space Is required)
<br /> Orange County Emergency Services shall be named additional insured's as
<br /> required by written contract., see VCAS2011 11/12 and CAS810 01/10, attached.
<br /> Waiver of Subrogation Applies, see VCAS9925 06111 and CAS$10 01/10,
<br /> attached.
<br /> LEE": Contract 2015-2016
<br /> CERTIFICATE HOLDER CANCELLATION
<br /> SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
<br /> Orange OL7Urt Emergency SerV[C THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
<br /> g County 9 Y ACCORDANCE WITH THE POLICY PROVISIONS,
<br /> 510 Meadowlands Drive
<br /> Hillsborough, NC 27278 AUTHORIZED REPRESENTATIVE
<br /> 'emu
<br /> OO 1988-2010 ACORD CORPORATION. All rights reserved.
<br /> ACORD 25(2010105) The ACORD name and logo are registered marks of ACORD
<br />
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