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HomeMy WebLinkAboutJefferson County Fair Association - 030821 (ins ex12.12.21-12.12.22 6-1-21) JCf - 3.it l rei"mn �2c27 C Grant Agreement by and Between Jefferson County G and ' Jefferson County Fair Association For Affordable Housing/Homelessness Services Grant Funding =5' WHEREAS, RCW 36.22.178 authorizes a recording fee surcharge to provide funding of affordable housing services; and ZA WHEREAS, RCW 36.22.179 authorizes a recording fee surcharge to provide funding for homeless housing and assistance; and WHEREAS, RCW 36.22.1791 authorizes an additional surcharge for local homeless housing and assistance; and WHEREAS, on February 4, 2021 the Housing Joint Oversight Board recommended funding levels for selected projects pursuant to a Request for Proposals for the funds collected pursuant to RCW 36.22.178, RCW 36.22.179, and, RCW 36.22.179; and WHEREAS, on February 16, 2021 the Jefferson County Board of Commissioners approved the Housing Joint Oversight Board's recommendation for funding; NOW, THEREFORE, Jefferson County, a political subdivision of the State of Washington, hereinafter referred to as "County," and Recipient, a non-profit corporation in Washington State (Recipient), in consideration of the mutual benefits, terms, and conditions hereinafter specified, do hereby agree as follows: 1. Grant Commitment. A 100% grant of funds is hereby made to Recipient for the Project described in Section 2. The approved maximum amount of the grant shall be $6,000, all from Fund 148. The grant ($6,000) shall be available based on submission of appropriate invoices pursuant to Section 3. 2. Project Description, Schedule and Budget. a. The scope of work for the Project is described in Exhibit A (attached). b. The Project begins on April 1, 2021 and shall be completed by on June 30, 2022. Work performed consistent with this Agreement on or after January 1, 2021, but prior to execution of this Agreement is hereby ratified. c. The budget for the Project is described in Exhibit B (attached). 3. Payment. a. Expenses incurred for the work performed on the Project, as described in Section 2, by the project's consultants, contractors, suppliers, or Recipient's staff shall be submitted to the County Administrator's Office by Recipient using a detailed invoice. Grant Agreement—Affordable Housing/Homelessness Services b. Each detailed invoice shall show individual items followed by the total amount incurred and the amount eligible for reimbursement under this grant. Recipient may submit such invoices to the County once per month during the course of the project for work completed. All invoices shall be submitted no later than 30 days after project completion. c. The County shall review and approve payment invoices. Payments will be limited to the monies that are available under the grant as described in Section 1. Such invoices, once approved, will be paid using the County's normal bill paying process and cycle. 4. Compliance with Laws. Recipient shall, in completing its project under this Grant Agreement, faithfully observe and comply with all federal, state, and local laws, ordinances, and regulations, applicable to the work to be completed under this Grant Agreement. 5. Indemnity. a. Recipient shall defend, indemnify and hold the County, its officers, officials, employees, agents and volunteers harmless from any and all claims, injuries, damages, losses or suits including attorney fees, arising out of or resulting from the acts, errors or omissions of Recipient in performance of this Agreement, except for injuries and damages caused by the sole negligence of the County. b. Should a court of competent jurisdiction determine that this Agreement is subject to RCW 4.24.115, then, in the event of liability for damages arising out of bodily injury to persons or damages to property caused by or resulting from the concurrent negligence of Recipient and the County, its officers, officials, employees, agents and volunteers, Recipient's liability, including the duty and cost to defend, hereunder shall be only to the extent of Recipient's negligence. c. It is further specifically and expressly understood that the indemnification provided in this Agreement constitutes Recipient's waiver of immunity under Industrial Insurance, Title 51 RCW, solely for the purposes of this indemnification. This waiver has been mutually negotiated by the parties. d. The provisions of this section shall survive the expiration or termination of this Agreement. 6. Required Insurance Coverages. a. Commercial General Liability. i. Recipient shall maintain commercial general liability coverage on a form acceptable to Jefferson County Risk Management for bodily injury, personal injury, and property damage, in an amount not less than two million dollars per occurrence ($2,000,000) and an aggregate of not less than four million dollars ($4,000,000), for bodily injury, including death, and property damage. Page 2 of 11 Grant Agreement—Affordable Housing/Homelessness Services ii. The commercial general liability insurance coverage shall contain no limitations on the scope of the protection provided and include the following minimum coverage: 1. Broad form property damage, with no employee exclusion; 2. Personal injury liability, including extended bodily injury; 3. Broad form contractual/commercial liability, including completed operations and product liability coverage; 4. Premises—operations liability (M&C); 5. Independent contractors and subcontractors; and, 6. Blanket contractual liability. i. Recipient's commercial general liability policy shall include employer's liability coverage. ii. The County and its elected officials, officers and employees shall be named as an additional insured party under this insurance policy. b. Automobile Liability. Recipient shall maintain business automobile liability insurance on a form acceptable to Jefferson County Risk Management with a limit of not less than a combined single limit of$1,000,000 each occurrence. Coverage shall include owned, hired, and non-owned automobiles. c. Worker's Compensation (Industrial Insurance). Recipient shall maintain workers' compensation insurance at its own expense, as required by Title 51 RCW, for the term of this Agreement and shall provide evidence of coverage to Jefferson County Risk Management, upon request. If the County incurs any costs to enforce the provisions of this subsection, all cost and fees shall be recoverable from Recipient. i. Recipient shall provide Workers Compensation and Employer's Liability Insurance on a state approved policy form providing benefits as required by law with employer/s liability limits no less than $1,000,000 per accident or disease. ii. This coverage shall extend to any contractor or subcontractor that does not have their own worker's compensation and employer's liability insurance. 7. Recipient expressly waives by mutual negotiation all immunity and limitations on liability, with respect to the County, under any industrial insurance act, disability benefit act, or other employee benefit act of any jurisdiction, which would otherwise be applicable in the case of such claim. 8. General Insurance Requirements. Page 3 of 11 Grant Agreement—Affordable Housing/Homelessness Services a. Insurance coverage shall be evidenced by one of the following methods: i. Certificate of insurance; or, ii. Self-insurance through an irrevocable Letter of Credit from a qualified financial institution. b. Any deductibles or self-insured retention shall be declared to and approved by the County prior to the approval of this Agreement by the County. At the option of the County, the insurer shall reduce or eliminate deductibles or self-insured retention, or Recipient shall procure a bond guaranteeing payment of losses and related investigations, claim administration and defense expenses. c. Failure of Recipient to take out or maintain any required insurance shall not relieve Recipient from any liability under this Agreement, nor shall the insurance requirements be construed to conflict with or otherwise limit the obligations concerning indemnification of the County. d. Recipient's insurers shall have no right of recovery or subrogation against the County (including its employees and other agents and agencies), it being the intention of the parties that the insurance policies so affected shall protect all the parties and shall be primary coverage for all losses covered by the above described insurance. e. Insurance companies issuing Recipient's insurance policy or policies shall have no recourse against the County (including its employees and other agents and agencies) for payment of any premiums or for assessments under any form of insurance policy. f. All deductibles in Recipient's insurance policies shall be assumed by and be at the sole risk of Recipient. g. Any judgments for which the County may be liable, in excess of insured amounts required by this Agreement, or any portion thereof, may be withheld from payment due, or to become due, to Recipient until Recipient shall furnish additional security covering such judgment as may be determined by the County. h. Any coverage for third party liability claims provided to the County by a "Risk Pool" created pursuant to Ch. 48.62 RCW shall be non-contributory with respect to any insurance policy Recipient shall provide to comply with this Agreement. i. The County may, upon Recipient's failure to comply with all provisions of this Agreement relating to insurance, withhold payment or compensation that would otherwise be due to Recipient. j. Recipient shall provide a copy of all insurance policies specified in this Agreement. k. Written notice of cancellation or change in Recipient's insurance required by this Agreement shall reference the project name and agreement number and shall be Page 4 of 11 Grant Agreement—Affordable Housing/Homelessness Services mailed to the County at the following address: Jefferson County Risk Management, P.O. Box 1220, Port Townsend, WA 98368. 1. Recipient's liability insurance provisions shall be primary and noncontributory with respect to any insurance or self-insurance programs covering the County, its elected and appointed officers, officials, employees, and agents. m. Any failure to comply with reporting provisions of the insurance policies shall not affect coverage provided to the County, its officers, officials, employees, or agents. n. Recipient's insurance shall apply separately to each insured against whom claim is made or suit is brought, except with respect to the limits of the insurer's liability. o. Recipient shall include all subcontractors as insured under its insurance policies or shall furnish separate certificates and endorsements for each subcontractor. All insurance coverage for subcontractors shall be subject to all the requirements stated in this Agreement. The insurance limits mandated for any insurance coverage required by this Agreement are not intended to be an indication of exposure nor are they limitations on indemnification. p. Recipient shall maintain all required insurance policies in force from the time services commence until services are completed. Certificates, insurance policies, and endorsements expiring before completion of services shall be promptly replaced. q. Recipient shall place insurance with insurers licensed to do business in the State of Washington and having A.M. Best Company ratings of no less than A-, with the exception that excess and umbrella coverage used to meet the requirements for limits of liability or gaps in coverage need not be placed with insurers or re-insurers licensed in the State of Washington. r. Certificates of insurance as required by this Agreement shall be delivered to the County within fifteen (15) days of execution of this Agreement. To the extent a certificate of insurance lists or refers to any endorsements solely by name, description or number it shall be the responsibility of Recipient to obtain and provide to the Jefferson County Risk Management full and complete copy of the texts of such endorsements. s. The County shall be named as an "additional insured" on all insurance policies required by this Agreement. t. Recipient shall furnish the County with properly executed certificates of insurance that, at a minimum, shall include: i. The limits of coverage; ii. The project name and agreement number to which it applies; Page 5 of 11 Grant Agreement—Affordable Housing/Homelessness Services iii. The certificate holder as Jefferson County, Washington and its elected officials, officers, and employees with the address of Jefferson County Risk Management, P.O. Box 1220, Port Townsend, WA 98368, and, iv. A statement that the insurance policy shall not be canceled or allowed to expire except on thirty (30) days prior written notice to the County. u. If the proof of insurance or certificate indicating the County is an "additional insured" to an insurance policy obtained by Recipient refers to an endorsement (by number or name) but does not provide the full text of that endorsement, then it shall be the obligation of Recipient to obtain the full text of that endorsement and forward that full text to the County. 9. Independent Contractor. Recipient and the County agree that Recipient is an independent contractor with respect to the project to be completed pursuant to this Grant Agreement. Nothing in this Grant Agreement shall be considered to create the relationship of employer and employee between the parties hereto. Neither Recipient nor any employee of Recipient, nor any subcontractor of Recipient shall be entitled to any benefits accorded to County employees by virtue of their services on the project to be completed under this Grant Agreement. The County shall not be responsible for withholding or otherwise deducting federal income tax or social security or for contributing to the State industrial insurance program, or otherwise assuming the duties of an employer with respect to Recipient, or any employee, representative or agent of Recipient, or any contractor of Recipient. 10. Subcontracting Requirements. a. Recipient Owns Contract Performance. Recipient is responsible for meeting all terms and conditions of this Agreement including standards of service, quality of materials and workmanship, costs, and schedules. Failure of a subcontractor to perform is no defense to a breach of this Agreement. Recipient assumes responsibility for and all liability for the actions and quality of services performed by any subcontractor. b. Subcontractor Disputes. Any dispute arising between Recipient and any subcontractors or between subcontractors must be resolved without involvement of any kind on the part of the County and without detrimental impact on the delivery of contracted goods and services. 11. Legal and Regulatory Compliance. While performing under this Agreement, Recipient, subcontractors, and their employees are required to comply with all applicable local, state and federal laws, codes, ordinances, and regulations, including but not limited to: a. Applicable regulations of the Washington Department of Labor and Industries, including WA-DOSH Safety Regulations; and, b. State and Federal Anti-Discrimination Laws. 12. Termination Page 6ofll Grant Agreement—Affordable Housing/Homelessness Services a. Termination by the County. i. Should Recipient default in providing services under this Agreement or materially breach any of its provisions, the County may terminate this Agreement upon ten (10) days written notice to Recipient. ii. Recipient shall have the right and opportunity to cure any such material breach within the ten(10) day period. iii. The County may terminate this Agreement upon immediate notice to Recipient. Recipient will be reimbursed for services expended up to the date of termination. iv. This Agreement may be terminated or amended, in whole or in part, by the County upon thirty (30) days written notice in the event expected or actual revenue to Funds 148 and/or 149 is reduced or limited in any way. b. Termination by Recipient. i. Should the County, its staff, employees, agents and/or representatives default in the performance of this Agreement or materially breach any of its provisions, Recipient, at its option, may terminate this Agreement by giving ten (10) days written notice to the County representative. ii. The County shall have the right and opportunity to cure any such material breach within the ten (10) day period. c. Termination Without Cause. This Agreement may be terminated without cause at any time by either party subject to a sixty (60) day advance written notice of such termination to the other party. 13. No Harassment or Discrimination. Recipient and any contractors/subcontractors will not discriminate against any person in the performance of work under this agreement or in the selection and retention of employees or procurement of materials or supplies on the basis of age, sex, marital status, sexual orientation, religion, creed, color, national origin, honorably discharged veteran or military status, or the presence of any sensory, mental, or physical disability or the use of a trained guide dog or service animal by a person with a disability, unless based upon a bonafide occupational qualification. 14. Contract Expiration. This contract shall run until the project is complete and until the County has made all payments required under this Grant Agreement, except that the project must be completed no later than Recipient, unless extended by mutual agreement. 15. Failure to Appropriate. Recipient acknowledges that the County may only appropriate monies for this grant in the current year and in a manner consistent with Paragraph 1 above. The County agrees to appropriate monies to fund this grant unless emergency circumstances prevent the County from doing so. Any monies to be paid by the County to Recipient for this grant are subject to appropriation by the County Commission. Page 7 of 11 Grant Agreement—Affordable Housing/Homelessness Services 16. Integrated Agreement. This Grant Agreement represents the entire and integrated agreement between the County and Recipient and supersedes all prior negotiations, representations, or agreements written or oral. 17. Modification of this Agreement. This Agreement may be amended or supplemented only by a writing that is signed by duly authorized representatives of all parties. 18. No Assignment. Recipient shall not sell, assign, or transfer any of rights obtained by this Agreement without the express written consent of the County. 19. Severability. Provided it does not result in a material change in the terms of this Agreement, if any provision of this Agreement or the application of this Agreement to any person or circumstance shall be invalid, illegal, or unenforceable to any extent, the remainder of this Agreement and the application this Agreement shall not be affected and shall be enforceable to the fullest extent permitted by law. 20. No Third-party Beneficiaries. The parties do not intend, and nothing in this Agreement shall be construed to mean, that any provision in this Agreement is for the benefit of any person or entity who is not a party. 21. Controlling Law. It is understood and agreed that this Agreement is entered into in the State of Washington. This Agreement shall be governed by and construed in accordance with the laws of the United States, the State of Washington and the County of Jefferson, as if applied to transactions entered into and to be performed wholly within Jefferson County, Washington 22. between Jefferson County residents. No party shall argue or assert that any state law other than Washington law applies to the governance or construction of this Agreement. (SIGNATURES APPEAR ON THE FOLLOWING PAGE) Page 8 of 11 Grant Agreement—Affordable Housing/Homelessness Services IN WITNESS WHEREOF, the parties have caused this Grant Agreement to be executed this 51 ,day of ./1, /1 V (/ , 2021. Jefferson County Jefferson County Fair Association Board of Commissioners 44/ cce 412,4d,..-- saiod/ Kate Dean, air Date Authorized Signatur Date <�u F'_ lltC.-4-riYve, /1/2aa. dp-e/ Print Name/Title ATTEST: / (4'14,r1 4011^74-i' 3/6 Carolyn Gallaway, CMC Date Clerk of the Board APPROVED AS TO FORM: 3/3/2021 Philip C. Hunsucker Date Chief Deputy Prosecuting Attorney Page 9 of 11 Grant Agreement—Affordable Housing/Homelessness Services EXHIBIT A PROJECT DESCRIPTION Name of Project: Fairgrounds Infrastructure and Capital Needs A. Amount requested: 148- Shelter services $ 6,000 • Provide a brief description of the project: The campgrounds are currently managed by the Jefferson County Fair Association and have been incurring costs since June 2020. Though the property is owned by Jefferson County, the property is under a Memorandum of Understanding and a Community Services Grant Agreement with the Jefferson County Fair association to operate and maintain all facilities and property there. The Jefferson County Fair Association will use the grant funds for infrastructure and capital needs associated with the homeless population camping there temporarily during a COVID pandemic- related eviction moratorium. • Specify the Project or Program goals and expected outcomes. Specify the methods by which the Project or Program will be measured and assessed: Goals include any of the following: improving the grounds by filling holes, leveling land, and graveling pathways. Warming devices will be attached to water lines so they do not need to be turned off in cold weather. Internet will be set-up to provide wi-fi for guests and security cameras. Funding to be used specifically for infrastructure and capital needs. Page 10 of 11 Grant Agreement—Affordable Housing/Homelessness Services EXHIBIT B SERVICE/OPERATING BUDGET Budget Categories Program Proposal Justification Priority Salaries $ $ Benefits $ $ Rental Subsidies $ $ Utilities $ $ Insurance $ $ Food/Supplies $ $ Furnishings/Equipment $ $ Repair/Maintenance $ $ 6,000 1 Transportation(explain) $ $ Subtotal $ $ Administration (10%max.) $ $ TOTAL $ $6,000 Page 11 of 11 JEFFERSON COUNTY BOARD OF COUNTY COMMISSIONERS CONSENT AGENDA REQUEST TO: Board of County Commissioners Philip Morley, County Administrator FROM: Mark McCauley, Central Services Director DATE: March 8, 2021 SUBJECT: AGREEMENT: re: Affordable Housing/Homelessness Grant Funding: In the Amount of$6,000: Jefferson County Administrator: Jefferson County Fair Association STATEMENT OF ISSUE: This agreement provides grant funding for 2021 to certain providers in Jefferson County. This funding will be budgeted in Fund 148, derived from recording fees and sales taxes, to address the housing needs of low income and homeless residents. Funding for the Jefferson County Fair Association for Infrastructure Costs was recommended by the Joint Oversight Board of the Homeless Housing Task Force. FISCAL IMPACT: This grant agreement is for $6,000 from Fund 148. A 1st Quarter supplemental budget request will be submitted to the Board of County Commissioners. RECOMMENDATION: That the Board of County Commissioners approve and sign the agreement. REV BY. `.mil Q/2d P ip or y, ounty Administrator Date vv�� c CONTRACT REVIEW FORM CONTRACT WITH: Jefferson County Fair Association TRACKING NO.: (Contractor/Consultant) CONTRACT FOR: Affordable Housing/Homelessness Grant TERM: Thru 4/30/22 COUNTY DEPARTMENT: Central Services For More Information Contact: Mark McCauley Contact Phone #: 360-385-9130 RETURN TO: Mark McCauley RETURN BY: ASAP (Person in Department) (Date) AMOUNT: $6,000 PROCESS: ❑ Exempt from Bid Process ❑ Consultant Selection Process Revenue N/A ❑ Cooperative Purchase Expenditure $6,000 ❑ Competitive Sealed Bid Matching funds Required N/A ❑ Small Works Roster Source(s)of Matching Funds N/A ❑ Vendor List Bid ▪ RFP or RFQ ❑ Other Step 1: REVIEW BY RISK M 1 Review by: �� // At. Date Reviewed: ir AAPPROVED FORM ❑ Returned for revision(See Comments) Comments ' A i)-3ro 44002..s. v�s `ace an.r" lr> ( Step 2: REVIEW BY PROSECUTING ATTORNEY Review by: `" Philip C. Hunsucker Date Reviewed: 3/3/2021 Chief Civil Deputy Prosecuting Attorney El APPROVED AS TO FORM ❑ Returned for revision(See Comments) Comments Step 3: (If required)DEPARTMENT MAKES REVISIONS & RESUBMITS TO RISK MANAGEMENT AND PROSECUTING ATTORNEY Step 4: CONTRACTOR/CONSULTANT SIGNS APPROPRIATE NUMBER OF ORIGINALS Step 5: SUBMIT TO BOCC FOR APPROVAL Submit original Contract(s),Agenda Request,and Contract Review form. Also,please send 2 copies of just the Contract(s)(with the originals)to the BOCC Office. Place"Sign Here"markers on all places the BOCC needs to sign. MUST be in BOCC Office by 4:30 p.m.TUESDAY for the following Monday's agenda. (This form to stay with contract throughout the contract review process.) R Y � Philip Morley From: Philip Morley Sent: Thursday, March 4, 2021 3:34 PM To: Mark McCauley;Julie Shannon Subject: Fairboard contract for capital & maintenance Mark, thanks for updating this agreement. I have a couple question or comments: • is the$6,000 funding out of 148 (affordable) or 149 (homeless)? Contract says 148, but would it make more sense to be from 149 if there's budget room there? Did the JOB specify which fund or leave it to us? • In EXHIBIT A, edit the sentence "The campgrounds are currently managed ... and have been incurring costs since June 2020 for utilities,trash removal , cleaning ..." to read instead: "The campgrounds are currently managed ... and have been incurring costs since June 2020." The reference to specific operating costs like utilities, etc. creates confusion that this grant is paying for those. It's not. Rather it's paying for infrastructure. • In EXHIBIT A, edit the sentence "Though the property is owned ...." to read instead: "Though the property is owned by Jefferson County,the property is under a Memorandum of Understanding and a Community Services Grant Agreement with the Jefferson County Fair association to operate and maintain all facilities and property there." • In EXHIBIT A, edit the sentence "The Jefferson County Fair Association will ... Overflow Emergency Shelter" with: "The Jefferson County Fair Association will use the grant funds for infrastructure and capital needs associated with the homeless population camping there temporarily during a COVID pandemic-related eviction moratorium." The reference in the original incorrectly references a Temporary COVID Overflow Emergency Shelter, which would needlessly confuse the people at the campground and the surrounding neighbors. Please make appropriate changes to the Grant Agreement and email or drop it off to Julie. She has a short day this Friday, so sooner will be better. Thank you. Philip Philip Morley Jefferson County Administrator pmorley@co.iefferson.wa.us (360) 385-9100 x-383 This is a reminder that all email to or from this email address may be subject to the Public Records Act contained in RCW 42.56. Additionally, all email to and from the county is captured and archived by Information Services. 1 1 i ..1C fourilffeeigitiri Q® DATE(MMIDD/YYYY) A lV(JR CERTIFICATE OF LIABILITY INSURANCE 05/27/2020 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(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 Christina Oakley NAME: The Partners Group Ltd (H ONE,Eat): (877)455-5640 FAX No): (425)455-6727 11225 SE 6th St. E-MAIL coakley@tpgrp.com ADDRESS: Suite 110 INSURER(S)AFFORDING COVERAGE NAIC N Bellevue WA 98004 INSURERA: Philadelphia Indemnity Ins Co 18058 INSURED INSURER B: Olympic Community Action Programs INSURER C: 823 Commerce Loop INSURER D: INSURER E: Port Townsend WA 98368 INSURER F: COVERAGES CERTIFICATE NUMBER: 20-21 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 ADDL SUER POLICY EFF POLICY EXP R TYPE OF INSURANCE LIMITS INSD WVD POLICY NUMBER (MM/DD/YYYY) (MM/DDIYYYY) X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE X OCCUR PREMISES(Ea occurrence) $ 100,000 MED EXP(Any one person) $ 5,000 A PHPK2137180 06/01/2020 06/01/2021 PERSONAL&ADVINJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERALAGGREGATE $ 2,000,000 X POLICY JECT PRO LOC PRODUCTS-COMP/OP AGG $ 2,000,000 OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ 1,000,000 (Ea accident) X ANY AUTO BODILY INJURY(Per person) $ A OWNED SCHEDULED PHPK2137180 06/01/2020 06/01/2021 BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS HIRED NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY _ AUTOS ONLY (Per accident) X UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 4,000,000 A EXCESS LIAB CLAIMS-MADE PHUB723734 06/01/2020 06/01/2021 AGGREGATE $ 4,000,000 DED X RETENTION$ 10,000 $ WORKERS COMPENSATION PER OTH- EL-WA Stop Gap v/N AND EMPLOYERS'LIABILITY STATUTE x ER , , A ANY PROPRIETOR/PARTNER/EXECUTIVE N/A PHPK2137180 06/01/2020 06/01/2021 E.L.EACH ACCIDENT $ 1 000 000 OFFICER/MEMBER EXCLUDED? (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 1,000,000 If yes,describe under 1000,000 - DESCRIPTION OF OPERATIONS below - - - - - E.L.DISEASE-POLICY LIMIT $ , - Each Claim $1,000,000 Professional Liability A PHPK2137180 06/01/2020 06/01/2021 Aggregate $2,000,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space is required) Certificate holder is included as Additional Insured as their interest may appear as required by written contract. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN Jefferson County Fair Association ACCORDANCE WITH THE POLICY PROVISIONS. PO Box 242 AUTHORIZED REPRESENTATIVE Port Townsend WA 98368 � I C. ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD 'if a i 5 3i`�-./ 1 i ,4Co CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYV) `....-,---- 05/27/2020 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(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 Christina Oakley NAME: The Partners Group Ltd PHONE (877)455-5640 FAX (425)455-6727 (A/C.No,Ext): (A/C,No): ) 11225 SE 6th St. E-MAIL coakley©tpgrp.com ADDRESS: Suite 110 INSURER(S)AFFORDING COVERAGE NAIC# Bellevue WA 98004 INSURERA: Philadelphia Indemnity Ins Co 18058 INSURED INSURER B: Olympic Community Action Programs INSURER C: 823 Commerce Loop INSURER D: INSURER E: Port Townsend WA 98368 INSURER F: COVERAGES CERTIFICATE NUMBER: 20-21 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 VVHICH 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 AUUL St POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER (MM/DD/YYYY) (MM/DD/YYYY) LIMITS X COMMERCIAL GENERAL /LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE /� OCCUR DAMAGE 10 RtNTED 100,000 PREMISES(Ea occurrence) $ MED EXP(Any one person) $ 5,000 A PHPK2137180 06/01/2020 06/01/2021 PERSONAL t:ADVINJURY $ 1,000,000 GEN'LAGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2.000,000 X POLICY PRO- LOC2,000,000 PRODUCTS-COMP/OPAGG $ OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ 1,000,000 (Ea accident) X ANY AUTO BODILY INJURY(Per person) $ A OWNED SCHEDULED PHPK2137180 06/01/2020 06/01/2021 BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS HIRED NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY _ AUTOS ONLY (Per accident) X UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 4,000,000 A EXCESS LIAB CLAIMS-MADE PHUB723734 06/01/2020 06/01/2021 AGGREGATE $ 4,000,000 DED X. RETENTION$ 10,000 $ WORKERS AND EMPLOYERS'LIABILON PER ITY Y/N STATUTE X ER EL-WA Stop Gap A ANY PROPRIETOR/PARTNER/EXECUTIVE N/A PHPK2137180 06/01/2020 06/01/2021 E.L.EACH ACCIDENT $ 1,000,000 OFFICER/MEMBER EXCLUDED? (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- Each Claim $1,000,000 A Professional Liability PHPK2137180 06/01/2020 06/01/2021 Aggregate $2,000,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space is required) Re:Community Development Block Grant Program Funds Evidence of Insurance CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN Jefferson County ACCORDANCE WITH THE POLICY PROVISIONS. PO Box 1220 AUTHORIZED REPRESENTATIVE Port Townsend WA 98368 dr_____ I E` ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD I y POLICY CHANGE DOCUMENT POLICY NO.: PHPK1987337 Philadelphia Indemnity Insurance Company 17331 The Partners Group, Ltd. NAMED INSURED Olympic Community Action Programs MAILING ADDRESS 823 Commerce Loop Port Townsend, WA 98368-2904 POLICY PERIOD: FROM 06/01/2019 TO 06/01/2020 at 12:01 A.M. Standard Time at your mailing address shown above. CHANGE EFFECTIVE 04/01/2020 CHANGE# 4 REVISION# 4 DESCRIPTION In consideration of the premium reflected, the policy is amended as indicated below: Added to all impacted coverage lines: Loc 35-3, 203E Otto St, Port Townsend, WA 98368 GL Class Code 68707 WAREHOUSE-PRIVATE-NFP Premium Basis 5,000 sq ft $25,000 Business Personal Property Amended: Blanket Business Personal Property limit accordingly Boiler and Machinery limit accordingly Per attached Path ID 13765591 Total Annual Total Prorate Additional/Return Premium$ 203.00 Additional/Return Premium$ 32.00 ADDITIONAL ADDITIONAL COUNTERSIGNED BY (Date) (Authorized Representative) 06/09/2020 Issue Date Insurance Policy Page 1 of 1 Philadelphia Indemnity Insurance Company Locations Schedule Policy Number: PHPK1987337 Prems. Bldg. No. No. Address 0001 0001 301 Lopez Ave Port Angeles, WA 98362-6529 0002 0001 328 E 7th St Port Angeles, WA 98362-6211 0003 0001 2321 S Francis St Port Angeles, WA 98362-6704 0004 0001 10 W Valley Rd Chimacum, WA 98325-7731 0005 0001 224 N Sequim Ave Bldg A Sequim, WA 98382-3455 0006 0001 294952 US Highway 101 Quilcene, WA 98376-8683 0007 0001 228 Thomas St Port Townsend, WA 98368-2268 0008 0001 2101 Haines St #1 Port Townsend, WA 98368-7810 0009 0001 2104 Haines St # 2 Port Townsend, WA 98368-7811 0010 0001 2042 Haines St # 3 Port Townsend, WA 98368-7838 0011 0001 2034 Haines St # 4 Port Townsend, WA 98368-7838 0012 0001 2028 Haines St # 5 Port Townsend, WA 98368-7838 0013 0001 2020 Haines St # 6 Port Townsend, WA 98368-7838 0014 0001 2050 Haines St # 7 Port Townsend, WA 98368-7838 0015 0001 2058 Haines St # 8 Port Townsend, WA 98368-7838 Page 1 of 3 Philadelphia Indemnity Insurance Company Locations Schedule Policy Number: PHPK1987337 Prems. Bldg. No. No. Address 0016 0001 711 Taylor St 709 Taylor Pfeiffer House Port Townsend, WA 98368-5529 0017 0001 228 W First Armory Square Ste 3 Port Angeles, WA 98362 0018 0001 823 Commerce Loop Port Townsend, WA 98368-2904 0019 0001 803 W Park Ave Port Townsend, WA 98368-2274 0020 0001 731 W Park Ave Port Townsend, WA 98368-2220 0021 0001 90A Faith Way Port Hadlock, WA 98339-9437 0022 0001 90B Faith Way Port Hadlock, WA 98339-9437 0023 0001 91C Faith Way Port Hadlock, WA 98339-9437 0024 0001 91D Faith Way Port Hadlock, WA 98339-9437 0025 0001 421 5th Ave Forks, WA 98331-9100 0026 0001 91 W Valley Rd # 918 Chimacum, WA 98325-7731 0027 0001 583 W Washington St Sequim, WA 98382-3280 0028 0001 1136 Water St Ste 112 Port Townsend, WA 98368-6728 0029 0001 2319 S Francis St Port Angeles, WA 98362-6704 0030 0001 2203 W 18th St Port Angeles, WA 98363-1507 Page 2 of 3 Philadelphia Indemnity Insurance Company Locations Schedule Policy Number: PHPK1987337 Prems. Bldg. No. No. Address 0031 0001 306144 US Highway 101 Brinnon, WA 98320-9690 0032 0001 209 Monroe St # A Port Townsend, WA 98368-5708 0033 0001 1637 Grant St Port Townsend, WA 98368-7622 0034 0001 90 County Shop Road Brinnon, WA 98320 0035 0001 203 Otto St Port Townsend, WA 98368-9780 0035 0002 203 Otto St Port Townsend, WA 98368-9780 0035 0003 203B Otto St Port Townsend, WA 98368-9780 Page 3 of 3 1 { Philadelphia Indemnity Insurance Company COMMERCIAL GENERAL LIABILITY COVERAGE PART SUPPLEMENTAL SCHEDULE Policy Number: PHPK1987337 Agent# 17331 Premium Rates Advance Premiums Basis Prem./ Prod./ Prem./ Prod./ Classifications Code No. Ops. Comp.Ops. Ops. Comp.Ops. WA PREM NO. 001 ADULT DAY CARE-NFP 40005 30 57.676 INCL 1,737 INCL PERSON PROD/COMP OP SUBJ TO GEN AGG LIMIT WA PREM NO. 002 STORE-FOOD/DRINK-NOC-NFP 18436 150,000 2.18E 0.496 329 75 GROSS SALES WA PREM NO. 003 SCHOOL-PRIV-ELEM/KINDRGRTN-NFP 47476 26 4.338 INCL 114 INCL STUDENT PROD/COMP OP SUBJ TO GEN AGG LIMIT WA PREM NO. 004 STORE-FOOD/DRINK-NOC-NFP 18436 19,088 2.188 0.496 43 10 GROSS SALES WA PREM NO. 004 HALL-NFP 44277 6,975 81.593 INCL 571 INCL AREA PROD/-COMP OP SUBJ TO GEN AGG LIMIT WA PREM NO. 005 SCHOOL-PRIV-ELEM/KINDRGRTN-NFP 47476 34 4.338 INCL 148 INCL STUDENT PROD/COMP OP SUBJ TO GEN AGG LIMIT WA PREM NO. 006 HALL-NFP 44277 3,850 81.593 INCL 315 INCL AREA PROD/COMP OP SUBJ TO GEN AGG LIMIT 1 t Philadelphia Indemnity Insurance Company COMMERCIAL GENERAL LIABILITY COVERAGE PART SUPPLEMENTAL SCHEDULE Policy Number: PHPK1987337 Agent# 17331 Premium Rates Advance Premiums Basis Prem./ Prod./ Prem./ Prod./ Classifications Code No. Ops. Comp.Ops. Ops. Comp.Ops. WA PREM NO. 007 APARTMENT BUILDING-NOC 60010 18 35.295 INCL 638 INCL UNIT PROD/COMP OP SUBJ TO GEN AGG LIMIT WA PREM NO. 008 DWELLING-1 FAM (LESSOR'S RISK) 63010 1 74.712 - INCL 76 - INCL DWELLING PROD/COMP OP SUBJ TO GEN AGG LIMIT WA PREM NO. 009 DWELLING-1 FAM (LESSOR'S RISK) 63010 1 74.712 INCL 76 INCL DWELLING PROD/COMP OP SUBJ TO GEN AGG LIMIT WA PREM NO. 010 DWELLING-1 FAM (LESSOR'S RISK) 63010 1 74.712 INCL 76 INCL DWELLING PROD/COMP OP SUBJ TO GEN AGG LIMIT WA PREM NO. 011 DWELLING-1 FAM (LESSOR'S RISK) 63010 1 74.712 INCL 76 INCL DWELLING PROD/COMP OP SUBJ TO GEN AGG LIMIT WA PREM NO. 012 DWELLING-1 FAM (LESSOR'S RISK) 63010 1 74.712 INCL 76 INCL DWELLING PROD/COMP OP SUBJ TO GEN AGG LIMIT WA PREM NO. 013 DWELLING-1 FAM (LESSOR'S RISK) 63010 1 74.712 INCL 76 INCL DWELLING PROD/COMP OP SUBJ TO GEN AGG LIMIT Philadelphia Indemnity Insurance Company COMMERCIAL GENERAL LIABILITY COVERAGE PART SUPPLEMENTAL SCHEDULE Policy Number: PHPK1987337 Agent# 17331 Premium Rates Advance Premiums Basis Prem./ Prod./ Prem./ Prod./ Classifications Code No. Ops. Comp.Ops. Ops. Comp.Ops. WA PREM NO. 014 DWELLING-1 FAM (LESSOR'S RISK) 63010 1 74.712 INCL 76 INCL DWELLING PROD/COMP OP SUBJ TO GEN AGG LIMIT WA PREM NO. 015 DWELLING-1 FAM (LESSOR'S RISK) 63010 1 74.712 INCL 76 INCL DWELLING PROD/COMP OP SUBJ TO GEN AGG LIMIT WA PREM NO. 016 DWELLING-1 FAM (LESSOR'S RISK) 63010 1 74.712 INCL 76 INCL DWELLING PROD/COMP OP SUBJ TO GEN AGG LIMIT WA PREM NO. 017 BLDG/PREMS-OFFICE-NOC-NFP 61227 29,324 120.106 INCL 3,554 INCL AREA PROD/COMP OP SUBJ TO GEN AGG LIMIT WA PREM NO. 018 BLDG/PREMS-OFFICE-NOC-NFP 61227 4,500 120.106 INCL 545 INCL AREA PROD./COMP OP SUBJ TO GEN AGG LIMIT WA PREM NO. 018 JANITORIAL SERVICE 96816 65,000 17.281 INCL 1,127 INCL PAYROLL PROD/COMP OP SUBJ TO GEN AGG LIMIT WA PREM NO. 018 SNOW/ICE REMOVAL-CONTRACTOR 99310 1,000 14.257 102.583 15 104 PAYROLL Philadelphia Indemnity Insurance Company COMMERCIAL GENERAL LIABILITY COVERAGE PART SUPPLEMENTAL SCHEDULE Policy Number: PHPK1987337 Agent# 17331 Premium Rates Advance Premiums Basis Prem./ Prod./ Prem./ Prod./ Classifications Code No. Ops. Comp.Ops. Ops. Comp.Ops. WA PREM NO. 018 LANDSCAPE GARDENING 97047 IF ANY 13.582 INCL INCL PAYROLL PROD/COMP OP SUBJ TO GEN AGG LIMIT WA PREM NO. 018 HOME HEALTH CARE SERVICE-NFP 44500 700,000 2.215 - INCL 1,557 INCL PAYROLL PROD/COMP OP SUBJ TO GEN AGG LIMIT WA PREM NO. 019 BLDG/PREM-BANK/OFF-MRC/MFG-NFP 61216 4,000 40.337 INCL 162 INCL AREA PROD/COMP OP SUBJ TO GEN AGG LIMIT WA PREM NO. 020 BLDG/PREM-BANK/OFF-MRC/MFG-NFP 61216 4,000 40.337 INCL 162 INCL AREA PROD/COMP OP SUBJ TO GEN AGG LIMIT WA PREM NO. 021 APARTMENT BUILDING-NOC 60010 4 35.295 INCL 142 INCL UNIT PROD/COMP OP SUBJ TO GEN AGG LIMIT WA PREM NO. 022 APARTMENT BUILDING-NOC 60010 4 35.295 INCL 142 INCL UNIT PROD/COMP OP SUBJ TO GEN AGG LIMIT WA PREM NO. 023 APARTMENT BUILDING-NOC 60010 3 35.295 INCL 107 INCL UNIT PROD/COMP OP SUBJ TO GEN AGG LIMIT Philadelphia Indemnity Insurance Company COMMERCIAL GENERAL LIABILITY COVERAGE PART SUPPLEMENTAL SCHEDULE Policy Number: PHPK1987337 Agent# 17331 Premium Rates Advance Premiums Basis Prem./ Prod./ Prem./ Prod./ Classifications Code No. Ops. Comp.Ops. Ops. Comp.Ops. WA PREM NO. 024 APARTMENT BUILDING-NOC 60010 4 35.295 INCL 142 INCL UNIT PROD/COMP OP SUBJ TO GEN AGG LIMIT WA PREM NO. 025 BLDG/PREMS-OFFICE-NOC-NFP 61227 100 120.106 INCL 13 - INCL AREA PROD/COMP OP SUBJ TO GEN AGG LIMIT WA PREM NO. 026 SCHOOL-PRIV-ELEM/KINDRGRTN-NFP 47476 17 4.338 INCL 75 INCL STUDENT PROD/COMP OP SUBJ TO GEN AGG LIMIT WA PREM NO. 027 BLDG/PREMS-OFFICE-NOC-NFP 61227 200 120.106 INCL 25 INCL AREA PROD/COMP OP SUBJ TO GEN AGG LIMIT WA PREM NO. 028 SHELTER/MISSION/STTLMNT/HALF H 67017 8,660 75.632 INCL 658 INCL AREA PROD/COMP-OP SUBJ TO GEN AGG LIMIT WA PREM NO. 028 BLDG/PREMS-OFFICE-NOC-NFP 61227 150 120.106 INCL 19 INCL AREA PROD/COMP OP SUBJ TO GEN AGG LIMIT WA PREM NO. 029 SCHOOL-PRIV-ELEM/KINDRGRTN-NFP 47476 26 4.338 INCL 114 INCL STUDENT PROD/COMP OP SUBJ TO GEN AGG LIMIT 1 l Philadelphia Indemnity Insurance Company COMMERCIAL GENERAL LIABILITY COVERAGE PART SUPPLEMENTAL SCHEDULE Policy Number: PHPK1987337 Agent# 17331 Premium Rates Advance Premiums Basis Prem./ Prod./ Prem./ Prod./ Classifications Code No. Ops. Comp.Ops. Ops. Comp.Ops. WA PREM NO. 030 SCHOOL-PRIV-ELEM/KINDRGRTN-NFP 47476 26 4.338 INCL 114 INCL STUDENT PROD/COMP OP SUBJ TO GEN AGG LIMIT WA PREM NO. 031 HALL-NFP 44277 4,000 81.593 INCL 327 INCL AREA PROD/COMP OP SUBJ TO GEN AGG LIMIT WA PREM NO. 032 SHELTER/MISSION/STTLMNT/HALF H 67017 4,000 75.632 INCL 304 INCL AREA PROD/COMP OP SUBJ TO GEN AGG LIMIT WA PREM NO. 033 SCHOOL-PRIV-ELEM/KINDRGRTN-NFP 47476 25 4.338 INCL 109 INCL STUDENT PROD/COMP OP SUBJ TO GEN AGG LIMIT WA PREM NO. 034 WAREHOUSE-PRIVATE-NFP 68707 600 29.103 INCL 18 INCL AREA PROD/COMP.OP SUBJ TO GEN AGG LIMIT WA PREM NO. 035 WAREHOUSE-PRIVATE-NFP 68707 2,600 29.103 INCL 77 INCL AREA PROD/COMP OP SUBJ TO GEN AGG LIMIT WA PREM NO. 035 WAREHOUSE-PRIVATE-NFP 68707 5,000 29.103 INCL 147 INCL AREA PROD/COMP OP SUBJ TO GEN AGG LIMIT Philadelphia Indemnity Insurance Company COMMERCIAL GENERAL LIABILITY COVERAGE PART SUPPLEMENTAL SCHEDULE Policy Number: PHPK1987337 Agent# 17331 Premium Rates Advance Premiums Basis Prem./ Prod./ Prem./ Prod./ Classifications Code No. Ops. Comp.Ops. Ops. Comp.Ops. WA LIABILITY DELUXE 44444 INCL BALANCE TO MEET PROD/COMP SUBLINE MINIMUM 44444 24 Change Date: 04/01/2020 PI-ULTD-002 11.98 ULTIMATECOVER PROPERTY COVERAGE PART DECLARATIONS Policy Number PHPK1987337 Effective Date: 06/01/2019 Expiration Date: 06/01/2020 12:01 a.m.,Standard Time l Extension of Declarations is attached Business Description Non Profit Organization Description of Premises Prem. No. Bldg.No. Location,Construction and Occupancy 0001 0001 301 Lopez Ave Port Angeles, WA 98362-6529 ADULT ACTION/ELDER DAYCARE FRAME 0002 0001 328 E 7th St Port Angeles, WA 98362-6211 RSVP/SR. NUTRITION FRAME 0003 0001 2321 S Francis St Port Angeles, WA 98362-6704 HEAD START-BLDG 1 FRAME 0004 0001 10 W Valley Rd Chimacum, WA 98325-7731 SR. NUTRITION/COMMUNITY ACTIVITIES FRAME 0005 0001 224 N Sequim Ave Bldg A Sequim, WA 98382-3455 HEAD START FRAME 0006 0001 294952 US Highway 101 Quilcene, WA 98376-8683 SR. NUTRITION/COMMUNITY ACTIVITIES FRAME Limits of Insurance Insurance applies only for coverage for which a Limit of Insurance is shown. Property at Specified Premises Prem. Bldg. Your Business Personal Property No. No. Personal Property of Others Buildings 0001 0001 BKT #2 0002 0001 BKT #2 0003 0001 BKT #2 BKT #1 0004 0001 BKT #2 0005 0001 BKT #2 BKT #1 0006 0001 BKT #2 Page 1 of 2 PI-ULTD-002 11.98 Personal Property at Location not Specifically Identified: $100,000, unless a higher limit is shown on the Additional Coverage Summary Declarations. Personal Property in Transit: $50,000, unless a higher limit is shown on the Additional Coverage Summary Declarations. These declarations are part of the policy declarations containing the Name of the Insured and the policy period. Applications of Limits D Specific ® Blanket-See Form PI-ULTD-006 0 Exceptions: Deductibles Building $ 2,500 Business Personal Property $ 2,500 Transit $ NONE Coinsurance 0 80% 0 90% 21 100% CM Agreed Value Mortgage Holders Prem. No. Bldg. No. Mortgage Holder Name and Address SEE SCHEDULE ATTACHED Forms and Endorsement Forms and endorsements applying to this Coverage Part and made part of this policy at time of issue: See Schedule of Forms and Endorsements attached. Premium Premium for this Coverage Part$ 12,797.00 Page 2 of 2 Change Date: 04/01/2020 PI-ULTD-003 11.98 PROPERTY COVERAGE PART EXTENSION OF DECLARATIONS Policy Number PHPK1987337 Description of Premises Prem.No. Bldg.No. Location,Construction and Occupancy 0007 0001 228 Thomas St Port Townsend, WA 98368-2268 SUPPORTIVE HOUSING/APARTMENTS - 18 UNIT FRAME 0008 0001 2101 Haines St #1 Port Townsend, WA 98368-7810 RENTAL DWELLING FRAME 0009 0001 2104 Haines St # 2 Port Townsend, WA 98368-7811 RENTAL DWELLING FRAME 0010 0001 2042 Haines St # 3 Port Townsend, WA 98368-7838 RENTAL DWELLING FRAME 0011 0001 2034 Haines St # 4 Port Townsend, WA 98368-7838 RENTAL DWELLING FRAME 0012 0001 2028 Haines St # 5 Port Townsend, WA 98368-7838 RENTAL DWELLING FRAME Limits of Insurance Insurance applies only for coverages for which a Limit of Insurance is shown. Property at Specified Premises Prem. Bldg. Your Business Personal Property No. No. Personal Property of Others Buildings 0007 0001 BKT #1 0008 0001 BKT #1 0009 0001 BKT #1 0010 0001 BKT #1 0011 0001 BKT #1 0012 0001 BKT #1 Mortgage Holders Prem.No. Bldg.No. Mortgage Holder Name and Address SEE SCHEDULE ATTACHED These declarations are part of the policy declarations containing the Name of the Insured and the policy period. Page 1 of 5 Change Date: 04/01/2020 PI-ULTD-003 11.98 PROPERTY COVERAGE PART EXTENSION OF DECLARATIONS Policy Number PHPK1987337 Description of Premises Prem.No. Bldg.No. Location,Construction and Occupancy 0013 0001 2020 Haines St # 6 Port Townsend, WA 98368-7838 RENTAL DWELLING FRAME 0014 0001 2050 Haines St # 7 Port Townsend, WA 98368-7838 RENTAL DWELLING FRAME 0015 0001 2058 Haines St # 8 Port Townsend, WA 98368-7838 RENTAL DWELLING FRAME 0016 0001 711 Taylor St Port Townsend, WA 98368-5529 BUILDING LRO JOISTED MASONRY 0017 0001 228 W First Armory Square Ste J Port Angeles, WA 98362 PA OFFICE FRAME 0018 0001 823 Commerce Loop Port Townsend, WA 98368-2904 ADMIN OFFICE NON-COMBUSTIBLE Limits of Insurance Insurance applies only for coverages for which a Limit of Insurance is shown. Property at Specified Premises Prem. Bldg. Your Business Personal Property No. No. Personal Property of Others Buildings 0013 0001 BKT #1 0014 0001 BKT #1 0015 0001 BKT #1 0016 0001 BKT #1 0017 0001 BKT #2 0018 0001 BKT #2 BKT #1 Mortgage Holders Prem.No. Bldg.No. Mortgage Holder Name and Address SEE SCHEDULE ATTACHED These declarations are part of the policy declarations containing the Name of the Insured and the policy period. Page 2 of 5 Change Date: 04/01/2020 PI-ULTD-003 11.98 PROPERTY COVERAGE PART EXTENSION OF DECLARATIONS Policy Number PHPK1987337 Description of Premises Prem.No. Bldg.No. Location,Construction and Occupancy 0019 0001 803 W Park Ave Port Townsend, WA 98368-2274 BUILDING LRO NON-COMBUSTIBLE 0020 0001 731 W Park Ave Port Townsend, WA 98368-2220 ARCHIVES & WORKING IMAGE NON-COMBUSTIBLE 0021 0001 90A Faith Way Port Hadlock, WA 98339-9437 SR: APTS - 4 UNITS FRAME 0022 0001 90B Faith Way Port Hadlock, WA 98339-9437 SR. APTS - 4 UNITS FRAME 0023 0001 91C Faith Way Port Hadlock, WA 98339-9437 SR. APTS - 3 UNITS & COMM ROOM FRAME 0024 0001 91D Faith Way Port Hadlock, WA 98339-9437 SR. APTS - 4 UNITS FRAME Limits of Insurance Insurance applies only for coverages for which a Limit of Insurance is shown. Property at Specified Premises Prem. Bldg. Your Business Personal Property No. No. Personal Property of Others Buildings 0019 0001 BKT #1 0020 0001 BKT #2 BKT #1 0021 0001 BKT #1 0022 0001 BKT #1 0023 0001 BKT #1 0024 0001 BKT #1 Mortgage Holders Prem.No. Bldg. No. Mortgage Holder Name and Address SEE SCHEDULE ATTACHED These declarations are part of the policy declarations containing the Name of the Insured and the policy period. Page 3 of 5 Change Date: 04/01/2020 PI-ULTD-003 11.98 PROPERTY COVERAGE PART EXTENSION OF DECLARATIONS Policy Number PHPK1987337 Description of Premises Prem.No. Bldg.No. Location,Construction and Occupancy 0025 0001 421 5th Ave Forks, WA 98331-9100 FORKS OFFICE FRAME 0026 0001 91 W Valley Rd # 918 Chimacum, WA 98325-7731 HEAD START ]OISTED MASONRY 0027 0001 583 W Washington St Sequim, WA 98382-3280 SOCIAL SERVICES ORGANIZATIONS FRAME 0029 0001 2319 S Francis St Port Angeles, WA 98362-6704 HEAD START - BLDG 2 FRAME 0030 0001 2203 W 18th St Port Angeles, WA 98363-1507 HEAD START FRAME 0031 0001 306144 US Highway 101 Brinnon, WA 98320-9690 SOCIAL SERVICES ORGANIZATIONS FRAME Limits of Insurance Insurance applies only for coverages for which a Limit of Insurance is shown. Property at Specified Premises Prem. Bldg. Your Business Personal Property No. No. Personal Property of Others Buildings 0025 0001 BKT #2 0026 0001 BKT #2 0027 0001 BKT #2 0029 0001 BKT #2 BKT #1 0030 0001 BKT #2 0031 0001 BKT #2 Mortgage Holders Prem.No. Bldg.No. Mortgage Holder Name and Address SEE SCHEDULE ATTACHED These declarations are part of the policy declarations containing the Name of the Insured and the policy period. Page 4 of 5 Change Date: 04/01/2020 PI-ULTD-003 11.98 PROPERTY COVERAGE PART EXTENSION OF DECLARATIONS Policy Number PHPK1987337 Description of Premises Prem.No. Bldg.No. Location,Construction and Occupancy 0032 0001 209 Monroe St # A Port Townsend, WA 98368-5708 BOARDING HOUSES FRAME 0033 0001 1637 Grant St Port Townsend, WA 98368-7622 HEAD START FRAME 0035 0001 203 Otto St Port Townsend, WA 98368-9780 WALK IN COOLER NON-COMBUSTIBLE 0035 0002 203 Otto St Port Townsend, WA 98368-9780 WALK IN FREEZER NON-COMBUSTIBLE 0035 0003 203E Otto St Port Townsend, WA 98368-9780 FOOD STORAGE NON-COMBUSTIBLE Limits of Insurance Insurance applies only for coverages for which a Limit of Insurance is shown. Property at Specified Premises Prem. Bldg. Your Business Personal Property No. No. Personal Property of Others Buildings 0032 0001 BKT #2 0033 0001 BKT #2 0035 0001 BKT #2 _ BKT #1 0035 0002 BKT #1 0035 0003 BKT #2 Mortgage Holders Prem.No. Bldg.No. Mortgage Holder Name and Address SEE SCHEDULE ATTACHED These declarations are part of the policy declarations containing the Name of the Insured and the policy period. Page 5 of 5 UltimateCover Program Blanket Limits Policy Number: PHPK1987337 Agent# 17331 ULTIMATECOVER PROPERTY—BLANKET STATEMENT OF VALUES Blanket Coverage Limit of Co- No. Insurance Insurance 1 Building $ 8,650,436 100% 2 Bus Per Prop $ 1,550,700 100% These declarations are part of the policy declarations containing the name of the insured and the policy period. Page 1 of 1 PI-ULTD-006 11.98 PI-ULT-023 07.01 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. BOILER AND MACHINERY ENDORSEMENT This endorsement modifies insurance provided under the following: Property Coverage Form Causes of Loss Form Business Income and Extra Expense Coverage Form Business Income Coverage Form Extra Expenses Coverage Form SCHEDULE Coverage Description Limit of Insurance Property Damage $ 10,201,136 Property Damage and Business Income/Extra Expense $ Business Income and Extra Expense $ 300,000 Business Income $ Extra Expense $ Sublimits of Insurance applicable to each covered location. These sublimits are part of and not in addition to the Limits of Insurance shown above. Coverage Sublimit of Insurance Ammonia Contamination $ 100,000 Water Damage $ 100,000 Hazardous Substances $ 100,000 Spoilage $ 100,000 Expediting Expense $ 100,000 Newly Acquired Location Coverage $ 1,000,000 Off Premises Service Interruption Business Income $ n/a Business Income and Extra Expense $ 300,000 Extra Expense $ n/a Spoilage _ $ 100,000 Ordinance or Law $ 250,000 Deductibles Coverage Deductible Property Damage $ 2,500 Business Income and Extra Expense 72 hours Business Income hours Extra Expense $ Spoilage Combined with PD Off Premises Service Interruption 72 hours Ammonia Contamination Combined with PD Other( ) $ Premium $ 1,163 Page 1 of 5 PI-ULT-023 07.01 A. Coverage For the purposes of this endorsement, the following exclusions and limitations, or parts thereof, are deleted as respects to the Boilers, Pressure Vessels and Machinery and Equipment at the described premises: Exclusion B.2.a. Artificially generated electric current, including electric arcing, that disturbs electrical devices, wiring or wires. Exclusion B.2.d.(2) The word latent is deleted. Exclusion B.2.d.(6) Mechanical breakdown, including rupture or bursting caused by centrifugal force. Exclusion B.2.e. Explosion of steam boilers, steam pipes, steam engines, steam turbines owned or leased by your, or operated under your control. Limitation C.1.a. Steam boilers, steam pipes, steam engines or steam turbines caused by or resulting from a condition or event inside such equipment. Limitation C.1.b. Hot water boilers or other water heating equipment caused by or resulting from any condition or event inside such boilers or equipment. B. Exclusions As respects the Boiler and Machinery coverage provided by this endorsement, coverage shall not include"loss" caused by or resulting from: 1. Damage while any boiler,fired or unfired vessel or electrical steam generator is undergoing a hydrostatic or gas pressure test; 2. Damage while any type of electrical or electronic equipment is undergoing an insulation breakdown test; 3. Damage to or destruction of media, however caused, and regardless of the function of that media; 4/ Depletion, deterioration, corrosion, erosion or wear or tear, and other gradually developing conditions. But if"loss"or damage otherwise covered by this endorsement ensues, we will pay for such ensuing'loss" C. Limits The most we will pay under this endorsement for direct"loss"to Covered Property is the Property Damage Limit of Insurance shown in the schedule of this endorsement. If Business Income Coverage, Extra Expense Coverage, or Business Income and Extra Expense Coverage is included in the policy to which this endorsement is a part, the most we will pay for those extensions of coverage under this endorsement are the respective Limits of Insurance shown in the schedule of this endorsement. All losses covered by this endorsement occurring at any one location which manifests themselves at the same time and are the result of the same cause will be considered a single loss. If an initial loss covered by this endorsement causes other losses covered by this endorsement, all will be considered a single loss. Page 2 of 5 PI-ULT-023 07.01 D. Extra Expediting This endorsement is extended to cover the reasonable extra cost of temporary repair and of expediting repair or replacement of Covered Property as a direct result of loss otherwise covered by this endorsement. The most we will pay under this extension is the amount shown as the Expediting Expense Sublimit in the schedule of this endorsement. E. Ammonia Contamination If Covered Property is contaminated by ammonia as a direct result of loss otherwise covered by this endorsement, the most we will pay for this kind of damage, including salvage expense, is the amount shown as the Ammonia Contamination Sublimit in the schedule of this endorsement. F. Water Damage If Covered Property is damaged by water as a direct result of loss otherwise covered by this endorsement, the most we will pay for this kind of damage, including salvage expense, is the amount shown as the Water Damage Sublimit in the schedule of this endorsement. G. Hazardous Substances If covered Property is contaminated by a hazardous substance as the direct result of loss otherwise covered by this endorsement, the most we will pay for expenses to clean up or dispose of such property is the amount shown as the Hazardous Substances Sublimit in the schedule of this endorsement. H. Spoilage If Covered Property spoils from lack of power, light, heat, steam, or refrigeration as a direct result of the Breakdown of the insured's Boilers, Pressure Vessels, Machinery or Equipment, the most we will pay for this kind of damage, including salvage expenses, is the amount shown as the Spoilage Sublimit in the schedule of this endorsement. I. Newly Acquired Locations The coverages of this endorsement are extended to the interest of the named insured in Boilers, Pressure Vessels, Machinery and Equipment, not otherwise insured, at newly constructed, acquired, or leased locations within the policy coverage territory and which have been previously undeclared. The most we will pay under this extension for loss or damage at any one location is the amount shown as the Newly Acquired Location Coverage Sublimit in the schedule of this endorsement. J. Off Premises Service Interruption If Off Premises Service Interruption Coverage is included in the policy of which this endorsement is a part, the coverage extensions of this endorsement for Business Income and/or Extra Expense and/or Spoilage are further extended to include loss caused by Boilers, Pressure Vessels, Machinery and Equipment, whether or not they are located on Insured's premises, owned by a public utility or other company and used to directly supply electrical power, communications services, heating, gas, water, steam or air conditions to the described premises. K. Deductibles There shall be liability under this endorsement only when the amount of loss exceeds the Boiler and Machinery Deductibles shown in the schedule of this endorsement. If no Boiler and Machinery Deductibles are shown, coverage under this endorsement is subject to the policy deductible. Page 3 of 5 PI-ULT-023 07.01 If an hour deductible is shown in the schedule, we will only pay for loss or damage you sustain after the first specified number of hours immediately following the physical loss to the Covered Property. If a multiplier is shown in the schedule of this endorsement, the deductible is determined by multiplying the One Hundred Percent Average Daily Value(100%ADV)times the multiplier. The 100%ADV will be obtained by dividing the total net profits, fixed charges and expenses for the entire location that would have been earned had no physical loss occurred during the period of interruption of business by the number of working days in that period. No reduction shall be made for net profits, fixed charges and expenses not being earned, or in the number of working days, because of the physical loss or damage or any other scheduled or unscheduled shutdowns during the period of interruptions. If a percent of loss deductible is indicated in the schedule of this endorsement,we will not be liable for the indicated percentage of loss or damage insured under this endorsement. If the dollar amount of such percentage is less than the indicated minimum deductibles, the minimum deductible will the applicable deductible. L. Suspension If any Boiler, Pressure Vessel, Machinery or Equipment covered by this endorsement is found to be in, or exposed to, a dangerous condition, any of our representatives may immediately suspend the coverage provided by this endorsement for that equipment by written notice mailed or delivered to: 1. Your last known address; or ' 2. The address where the affected equipment is located. Once suspended in this way, your insurance can be reinstated only by endorsement. If we suspend your insurance, you will get a pro rata refund for the affected equipment. But the suspension will be effective even if we have not yet made or offered a refund. M.Mechanical or Electrical Breakdown With respect to coverage provided by this endorsement, Mechanical or Electrical Breakdown means a sudden and accidental breakdown of covered Boilers, Pressure Vessels, Machinery and Equipment. At the time breakdown occurs, it must become apparent by physical damage that requires repair or replacement of the affected equipment or part of the affected equipment. Mechanical or Electrical Breakdown does not mean or include any of-the following: 1. Breakdown of any structure or foundation. 2. Breakdown of any boiler setting, insulating or refractory material. 3. Breakdown of a power shovel, dragline, excavator, vehicle, aircraft, floating vessel or structure, well casing, penstock or draft tube. 4. Breakdown of any elevator, crane, hoist, escalator or conveyor, but not including any pressure vessel or electrical equipment used with such a machine. 5. Breakdown of Boilers, Pressure Vessels, Machinery or Equipment manufactured or held for sale by you. 6. Breakdown of catalyst. Page 4 of 5 „ PI-ULT-023 07.01 7. Breakdown of any oven, stove,furnace, incinerator, pot or kiln. 8. Breakdown of any buried vessel or piping. 9. Breakdown of a felt, wire, screen, die, mold, form, pattern, extrusion plate, swing hammer, grinding disc, cutting blade, chain, cable, belt, rope, clutch plate, brake pad, nonmetallic part or any part or tool subject to frequent, periodic replacement. 10. Breakdown, of any nonmetallic vessel, unless it is constructed and used in accordance with the American Society of Engineers(A.S.M.E.)code. 11. Breakdown of sewer piping, piping forming a part of a fire protection system or water piping other than: a. Feed water piping between any boiler and its feed pump or injector; or b. Boiler condensate return piping; or c. Water piping forming a part of refrigerating and air conditioning vessels and piping used for cooling, humidifying or space heating purposes. 12. Breakdown of a part of a Boiler, Pressure Vessel or Electric Steam Generator that: a. Does not contain steam or water; or b. Is not under pressure of contents of the vessel; or c. Is not under internal vacuum. 13. The functioning of any safety or protective devices. Page 5 of 5 Client#: 2062 JEFFECOU ACORD„ CERTIFICATE OF LIABILITY INSURANCE °ATE(MM/DDNYYY) THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS1 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 any rights to the certificate holder in lieu of such endorsement(s). PRODUCER C t�TACT Haas&Wilkerson Insurance N$ME: Debbie Johnson PHONE _ 4300 Shawnee Mission Parkway ENMC,No,EX1_913 432-4400 (NC,pro:): 913 432-6159 _. Fairway,KS 66205 ADDRESS. •debbie.johnson�hwins.com 913 432.4400 INSURER(S)AFFORDING COVERAGE NMI INSURER A:ACE American Insurance Company(CHUBS) 22667 INSURED _.._ Jefferson County Fair Association INSURER e PO BOX 242 INSURER C: Port Townsend,WA 98368 INSURER D INSURER E: INSURER F: - 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 LTR TYPE OF INSURANCE POLICY EFF POLICY EXP iINOR WVD, POLICY NUMBER LMM/DDlYYYYL(MM/DD/YYYY) LIMITS A X COMMERCIAL GENERALLUU3IUTY � ...__ G21438637 12/12/2021 12/12/2022 EA H OCCURRENCE $1,000,000 ......I CLAIMS MADE XI OCCUR GE O RENTED I .._. — t i �RoSE ,Eaocaurence) $500,000 , __— MED EXP(My one person) $Excluded PERSONAL 8 ADV INJURY s 1,000,000 GEN'L AGGREGATE UMIT APPLIES PER_ POLICY JEta I GENERAL AGGREGATE $5,000,000 LOC PRODUCTS-COMP/-COMP/OP I$5 OTHER , ,000,000 A AUTOMOBILE UASIUTY H08121746 12/12/2021 12/12/20 COMBINED SING&LIMIT 1$ ANYANYAUpTO 2?i tEaacaderq $1,000,000 • A ONLY �SCHEDULED i BODILY INJURY(Per person( $ X�AUTOS ONLY ^ 7 NON OWNED €IIAUTOS . BODILY INJURY(Per accident) $ --1 AUTOS ONLY t PROPERTY DAMAGE ..._._ i 1(Per acadeM) I$ 1 I UMBRELLA UAB .... .. OCCUR.._ _.._... -_ _........__ I i$ EXCESS LIAR EACH OCCURRENCE S CLAIMS-MADE I r �__ .__ i AGGREGATE $ DED RETENTIONS ' WORKERS COMPENSATION ! j AND EMPLOYERS BI UAUTY i �� S I ANY PROPRIETOR/PARTNERIE)(ECUTVE.Y IN— OFFICER/MEMBER EXCLUDED? t N!A $ E.L.EACH ACCIDENT(Mandatory In NH) _._ It yes deso'Ibe Ut>ner l E L DISEASE-EA EMPLOYEE!$ DESCRIPTION OF OPERATIONS below Ii E.L.DISEASE-POLICY LIMIT I S • DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Romans Schedule,may be attached if more space is required) Governmental Entity(Form CG2026/LD-22318) The certificate holder is named as an additional insured on the general liability policy but only with respect to liability arising out of the named insured's operations or premises owned by or rented to the named insured per form CG2026/LD-22318. This insurance is primary and non-contributory. Wavier of Subrogation applies in favor of certificate holder. 30 days written notice of cancellation will be provided except for non-payment of premium,which is 10 days notice. CERTIFICATE HOLDER CANCELLATION Jefferson County SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE PO Box 1220 THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Port Townsend,WA 98368 AUTHORIZED REPRESENTATIVE ACORD 25(2016/03) 1 of 1 The ACORD name and logo are registered marks of A ORD$-2015 ACORD CORPORATION.All rights reserved. #S512038/M512037 ANDRB