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Home My WebLink About3 - Legal Review Submission_ PAPE COI ACORD Form 20220323-10054903/23/2022 HENTSCHELL & ASSOC INC 1436 S. Union Ave. Tacoma WA 98405-1925 Danielle Bryant (253) 272-1151 (253) 272-1225 danielleb@hentschell.com Pape & Sons Construction, Inc. 9401 Bujacich Road Suite 1A Gig Harbor WA 98332 The Charter Oak Fire Ins. Co 25623 The Travelers Indemnity Co. of America 25658 Travelers Prop Cas Co of America 25674 21-22 A Y Y DTCO0J154095COF21 12/31/2021 12/31/2022 1,000,000 300,000 10,000 1,000,000 2,000,000 2,000,000 WA StopGap/Empl Liab 1,000,000 B Y Y BA1L6589552126G 12/31/2021 12/31/2022 1,000,000 C 10,000 Y Y CUP0J4039462126 12/31/2021 12/31/2022 5,000,000 5,000,000 WASHINGTON STATE FUND 12/31/2021 12/31/2022 C INSTALLATION FLOATER 630-9S118521-TIL-21 12/31/2021 12/31/2022 1,000,000 LIMIT - EACH JOB SITE LOC. 100,000 LIMIT - IN TRANSIT 100,000 LIMIT - TEMP.LOCATION Project: Oyster Bay Avenue Force Main Replacement Blanket Primary Non-Contributory Additional Insured, including completed operations and Blanket Waiver of Subrogation applies in favor of any person ororganization if called for by written contract or agreement, per policy forms and conditions; #CGD316 02/19, CGD246 04/19, CGD211 01/04, CGT100 0/19, CAT353 02/15 - City of Bremerton, its officials, employees, agents and volunteers are all included as additional insured City of Bremerton 345 - 6th Street Suite 100 Bremerton WA 98337 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. INSURER(S) AFFORDING COVERAGE INSURER F : INSURER E : INSURER D : INSURER C : INSURER B : INSURER A : NAIC # NAME:CONTACT (A/C, No):FAX E-MAILADDRESS: PRODUCER (A/C, No, Ext):PHONE INSURED REVISION NUMBER:CERTIFICATE NUMBER:COVERAGES 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). 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. OTHER: (Per accident) (Ea accident) $ $ N / A SUBR WVD ADDL INSD 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. $ $ $ $PROPERTY DAMAGE BODILY INJURY (Per accident) BODILY INJURY (Per person) COMBINED SINGLE LIMIT AUTOS ONLY AUTOSAUTOS ONLY NON-OWNED SCHEDULEDOWNED ANY AUTO AUTOMOBILE LIABILITY Y / N WORKERS COMPENSATION AND EMPLOYERS' LIABILITY OFFICER/MEMBER EXCLUDED?(Mandatory in NH) DESCRIPTION OF OPERATIONS belowIf yes, describe under ANY PROPRIETOR/PARTNER/EXECUTIVE $ $ $ E.L. DISEASE - POLICY LIMIT E.L. DISEASE - EA EMPLOYEE E.L. EACH ACCIDENT EROTH-STATUTEPER LIMITS(MM/DD/YYYY)POLICY EXP(MM/DD/YYYY)POLICY EFFPOLICY NUMBERTYPE OF INSURANCELTRINSR DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) EXCESS LIAB UMBRELLA LIAB $EACH OCCURRENCE $AGGREGATE $ OCCUR CLAIMS-MADE DED RETENTION $ $PRODUCTS - COMP/OP AGG $GENERAL AGGREGATE $PERSONAL & ADV INJURY $MED EXP (Any one person) $EACH OCCURRENCEDAMAGE TO RENTED $PREMISES (Ea occurrence) COMMERCIAL GENERAL LIABILITY CLAIMS-MADE OCCUR GEN'L AGGREGATE LIMIT APPLIES PER: POLICY PRO-JECT LOC CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DD/YYYY) CANCELLATION AUTHORIZED REPRESENTATIVE ACORD 25 (2016/03) © 1988-2015 ACORD CORPORATION. All rights reserved. CERTIFICATE HOLDER The ACORD name and logo are registered marks of ACORD HIREDAUTOS ONLY DocuSign Envelope ID: 46F33129-F5E4-475B-8443-C1EFD4E535D7 DocuSign Envelope ID: 46F33129-F5E4-475B-8443-C1EFD4E535D7 DocuSign Envelope ID: 46F33129-F5E4-475B-8443-C1EFD4E535D7 DocuSign Envelope ID: 46F33129-F5E4-475B-8443-C1EFD4E535D7 DocuSign Envelope ID: 46F33129-F5E4-475B-8443-C1EFD4E535D7 DocuSign Envelope ID: 46F33129-F5E4-475B-8443-C1EFD4E535D7 DocuSign Envelope ID: 46F33129-F5E4-475B-8443-C1EFD4E535D7 DocuSign Envelope ID: 46F33129-F5E4-475B-8443-C1EFD4E535D7 DocuSign Envelope ID: 46F33129-F5E4-475B-8443-C1EFD4E535D7 DocuSign Envelope ID: 46F33129-F5E4-475B-8443-C1EFD4E535D7 DocuSign Envelope ID: 46F33129-F5E4-475B-8443-C1EFD4E535D7 DocuSign Envelope ID: 46F33129-F5E4-475B-8443-C1EFD4E535D7 DocuSign Envelope ID: 46F33129-F5E4-475B-8443-C1EFD4E535D7 DocuSign Envelope ID: 46F33129-F5E4-475B-8443-C1EFD4E535D7 DocuSign Envelope ID: 46F33129-F5E4-475B-8443-C1EFD4E535D7 DocuSign Envelope ID: 46F33129-F5E4-475B-8443-C1EFD4E535D7 DocuSign Envelope ID: 46F33129-F5E4-475B-8443-C1EFD4E535D7 DocuSign Envelope ID: 46F33129-F5E4-475B-8443-C1EFD4E535D7 DocuSign Envelope ID: 46F33129-F5E4-475B-8443-C1EFD4E535D7 DocuSign Envelope ID: 46F33129-F5E4-475B-8443-C1EFD4E535D7 DocuSign Envelope ID: 46F33129-F5E4-475B-8443-C1EFD4E535D7 DocuSign Envelope ID: 46F33129-F5E4-475B-8443-C1EFD4E535D7 DocuSign Envelope ID: 46F33129-F5E4-475B-8443-C1EFD4E535D7 DocuSign Envelope ID: 46F33129-F5E4-475B-8443-C1EFD4E535D7 DocuSign Envelope ID: 46F33129-F5E4-475B-8443-C1EFD4E535D7 DocuSign Envelope ID: 46F33129-F5E4-475B-8443-C1EFD4E535D7 DocuSign Envelope ID: 46F33129-F5E4-475B-8443-C1EFD4E535D7 DocuSign Envelope ID: 46F33129-F5E4-475B-8443-C1EFD4E535D7 DocuSign Envelope ID: 46F33129-F5E4-475B-8443-C1EFD4E535D7 DocuSign Envelope ID: 46F33129-F5E4-475B-8443-C1EFD4E535D7 DocuSign Envelope ID: 46F33129-F5E4-475B-8443-C1EFD4E535D7 DocuSign Envelope ID: 46F33129-F5E4-475B-8443-C1EFD4E535D7 DocuSign Envelope ID: 46F33129-F5E4-475B-8443-C1EFD4E535D7