2021.0322.FW0005 WAS2132 InsuranceACCVREP CERTIFICATE OF LIABILITY INSURANCE
1...�� I v1/2021
DATE(MMIDONYYY)
1 11/2/2020
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 dues not confer ri hts to the certificate holder in lieu of such endorsement(s).
PRODUCER Lockton Companies
3280 Peachtree Road NE, Suite #1:250
Atlanta GA 30305
(404)460-3600
CONTACT
PHONE FAX
A!C No
E-MAIL
ADDRESS:
S18G1,00242-201
11/1/2020
INSURER(SAFFORDING COVERAGE NAIC #
INSURER A: Everest Indemnity Insurance Company 10851
PREMISES Ea occurrence S 500,000
INSURED American Promotional Events, Inc.
INSURER B ;
INSURER C:
1359629 DBA TNT Fireworks, Inc.
P.O. BOX 1318
4511 Helton Drive
INSURER D
$
Florence AL 35630
INSURER E
LIABILITY
ANY AUTO
OWNED SCHEDULED
AUTOS ONLY AUTOS
HIRED NON -OWNED
ONLY AUTOS ONLY
INSURER F
COVERAGES' CERTIFICATE NUMBER: 1744t1BR4 REVISION NIIMAPR• xxyxyyy
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 LIRTYPE
OF INSURANCE
ADDL
SUBR
POLICY NUMBER
MOLIC F
YYY
POLICY
OLIO
YI YY
LIMITS
A
X COMMERCIAL GENERAL LIABILITY
CLAIMS -MADE 5XI OCCURAMA
Y
N
S18G1,00242-201
11/1/2020
l 1/l/2021
EACH OCCURRENCE S 1,000,000
PREMISES Ea occurrence S 500,000
MED EXP (Any ons person) $ 5 000
PERSONAL & ADV INJURY S 1.000,000
GEN'LAGGREGATE LIMIT APPLIES PER:
POLICY ❑ JECT FRI LOC
OTHER:
GENERAL AGGREGATE S 2,000,000
PRODUCTS - COMP/OP AGG S 2000000
$
AUTOMOBILE
LIABILITY
ANY AUTO
OWNED SCHEDULED
AUTOS ONLY AUTOS
HIRED NON -OWNED
ONLY AUTOS ONLY
NOT APPLICABLEOMBINE❑
IN LE LIMIT
Ea accident $ XXXXXXX
BODILY INJURY (Per person) S XXXXXX.X
tid
(Per accident)
BODILY I { } S XXXXXXX
PROPERTY DAMAGE $ XXXXXXX
Per accfdont
$XXXXXXX
UMBRELLA LIAR
EXCESS UAB
OCCUR
CLAIMS -MADE
NOT APPLICABLE
EACH OCCURRENCE $ XXXXXXX
AGGREGATE S XXXXXXX
DEO I I RETENTION $
S XXXX=
WORKERS COMPENSATION
AND EMPLOYERS' LIABILITY Y 1 N
ANY PROPRIETORIPARTNERIEXECUTNEE.L.
OFFICERIMEMBER EXCLUDED? F-1
yandatory In NH)
(M
DESCRIPTION OF OPERATIONS below
N 1 A
NOT APPLICABLE
STATUTE ETH
EACH ACCIDENT S XXXXXXX
E.L. DISEASE- EA EMPLOYEE S XXXX XXX
E1. DISEASE- POLICY LIMIT S XXXXXXX
DESCRIPTION OF OPERATIONS! LOCATIONS I VEHICLES (ACORD tpt, Additional Remarks Schedule, may be attached if more spaca is required)
Located at Safeway 1109 Yelm Ave E. Yelm, WA (WAS2132) Certificate holder is an additional insured on the General Liability as required by written contract
Subject to policy terms, conditions, and exclusions.
I.CK 1 Irl IA I C rIUL.IJtZK S:ANGELLATIUN
12340084
City of Yelm
Yelm Jesus Name Pentecostal Church
PO Bax 479
Yelm WA 98597
SHOULD ANY OF THE ABOVE: DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
AUTHORIZED
TION. All riahts reswrvnd
ACORD 25 (2016103) The ACORD name and logo are registered marks of ACORD