2021.0326.FW0006 WAS2133 InsuranceALCOR�D® CERTIFICATE OF LIABILITY INSURANCE
11 /l12021
DATE{MMroblYYYY}
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 does not confer rights to the certificate holder In lieu of such endorsement(s).
PRODUCER Lockton Companies
3280 Peachtree Road NE, Suite 9250
Atlanta GA 30305
(404) 460-3600
CONTACT
PHONE FAX
M. No. Exilm AIC No '
E-MAIL
ADDRESS:
818CL00242-201
11/1/2020
INSURERS AFFORDING COVERAGE NAIL
INSURER A: Everest Indemnity Insurance Company 10851
PREMISES Eaaccurrence S 500,000 w
INSURED American Promotional Events, Inc.
INSURER B:
INSURER C:
1359629 DBA TNT Fireworks, Inc.
P.O. BOX 1318
4511 Helton Drive
Florence AL 35630
INSURER D:
INSURER E:
lyfltlt
INSURER F:
COVERAGES CERTIFICATE NUMBER: 12934924 REVISION NUMBER: X7f'K'Xxy_Y
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.
INSR1
TR
TYPE OF INSURANCE
ADDL
SUER
POLICY NUMBER
POLICY EFF
MMIDDIYYYY
POLICY EXP
MMIDDIYYYY
LIMITS
A
X COMMERCIAL GENERAL LIABILITY
CLAIMS -MADE x_ OCCUR
Y
N
818CL00242-201
11/1/2020
11/1/2021
EACH OCCURRENCE $ 1,00 OOO
PREMISES Eaaccurrence S 500,000 w
MED EXP (Any ono porson) 5 5,000
PERSONAL & ADV INJURY s 1,0002000
GENR'L AGGREGATE: LIMIT APPLIES PER:
POLICY O JEC FX� LOC
OTHER:
GENERAL AGGREGATE S 2,000,000
PRODUCTS- COMPIOP qGG 5 2.000,000
AUTOMOBILE
LIABILITY
ANY AUTO
OWNED AUTOS ONLY AUTOS
H RED NON -OWNED AUTOS ONLY AUTO ONLY
NOT APPLICABLE
COMBINED SINGLE LIMIT
Ea accident) $ XXXXXXX
BODILY INJURY (Per person) 5 XXXXXXX
BODILY INJURY {Por accidont) S XXXXXXX
Peflr ac is deniDAGE g XXXI��XXX
sXXXXXXX
UMBRELLA LIAB
EXCESS LIAR
HCLAIMS-MADE
OCCUR
NOT APPLICABLE
EACH OCCURRENCE $XXXXXXX
AGGREGATE S XXXXXXX
DED I I RETENTIONS
5 XXXXXXX
WORKERS COMPENSATION
AND EMPLOYERS' LIABILITY Y 1 N
ANY PROPRIETORIPARTNERIEXECUTIVE
OFFICER/MEMBER EXCLUDED' El
(Mandatory In NH)
If yes, desedba under
DESCRIPTION OF OPERATIONS below
N I A
NOT APPLICABLESTATUTE
ERH
E.L. EACH ACCICENT S XXXXXXX
E.L. DISEASE- EA EMPLOYEE S XXXXXXX
E.L. DISEASE- POLICY LIMIT $ XXXXXXX
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schadulo, may bo atlaehed it mora space is required)
PROPERTY LOCATED AT WALMART 17100 SR 507 SE YELM WA (WAS2133) Certificate holder is an additional insured on the General Liability as required
by written contract subject to policy terms, conditions, and exclusions.
r m.A I C MULUCK
12934924
CITY OFYELM
YELM JESUS NAME PENTECOSTAL CHURCH
PO BOX 749
YELM WA 98597
ACORD 25 (2016103)
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
Q
The ACORD name and logo are registered marks of ACORD
TION. All riahts reserved