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City of Bremerton 233-1896-178
Downtown Bicycle Pedestrian Circulation Improvements I-63 June 2021
Contract Documents Insurance Questionnaire
INSURANCE QUESTIONNAIRE
NOTE: THIS QUESTIONNAIRE MUST BE COMPLETED AND ATTACHED TO THE
CERTIFICATE OF INSURANCE
For
(Name of Insured)
Project Name
Project Owner
ARE THE FOLLOWING COVERAGES AND/OR CONDITIONS IN EFFECT?
YES NO
The Policy form is ISO Commercial General Liability from
CG 00 01 or CG 00 02 (circle one). If NO, attach a copy of the
policy with required coverage clearly identified.
Products and Completed Operation coverage.
Cross Liability Clause (or equivalent wording).
Personal Injury Liability (with employee exclusion deleted).
Broad Form Property Damage with X, C, U Hazards included
Blanket Contractual Liability coverage applying to this Contract
Employers Liability – Stop Gap
Deductibles or SIR's GL AL Excess
Insurer's Best Rating GL AL Excess
This Questionnaire is issued as a matter of information. This Questionnaire is not an insurance policy
and does not amend, extend or alter the coverage afforded by the policies indicated on the attached
Certificate of Insurance.
Agency/Broker Completed by (print or type)
Address Completed by (signature)
Name of Person to Contact Telephone Number
Sound Pacific Construction LLC
X
X
X
X
X
X
X
0 0 10,000
A+A+A+
Rice Insurance LLC
1400 Broadway, Bellingham WA 98225
Rita Larsen
Rita Larsen
360-734-1161
DocuSign Envelope ID: 35E3A1CF-FE1C-453D-9E00-0C7441C83B62