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' 1 ACORO, CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) ka..------ Month/Date/Year 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 NAME: PHNInsurance Agent/Broker Name IIA//C. o.Extl: d vvc,No)E-MAIL : Insurance Agent/Broker Street Address or P.O.Box ADDRESS: City,State,and Zip Code INSURER(S)AFFORDING COVERAGE NAIC# Contact and Phone Number INSURER A: Name of Insurance Enter NAIC# INSURED INSURER B: Name of Insurance Company(if applicable) Enter NAIC# Customer Name INSURER c: Name of Insurance Company(if applicable) Enter NAIC# Customer Street Address or P.O.Box INSURERD: City,State,and Zip Code INSURERS: 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. INSR ADDL SUBR POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER (MM/DD/YYYY) IIONYYY) LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE A DAMAGE TO RENTED $ 1,000,000 X CLAIMS-MADE X OCCUR X PREMISES(Ea occurrence) $ 100,000 Enter Policy Number Ente nter MED EXP(Any one person) $ N/A Effe xpiration t Date PERSONAL 8,ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 X POLICY JECTT LOC • PRODUCTS-COMP/OP AGG $ 1,000,000 OTHER: $ AUTOMOBILE LIABILITY 41II" COMBINED SINGLE LIMIT $ (Ea accident) ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED AUTOS ONLY AUTOS 0 I BODILY INJURY(Per accident) $ HIRED NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY AUTOS ONLY (Per accident) $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE `0 AGGREGATE $ DED I I RETENTION$ $ COMPENSATION.WORKERS PER ' AND EMPLOYERS'L ABILITY Y/N STATUTE EORH ANYPROPRIETORIPARTNER/EXECUTIVE E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED', n N/Aici‘ (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ If yes,describe under DESCRIPTION OF OPERATIONS below E .DISEASE-POLICY LIMIT $ Other:Property,Equipment,Inland Marine,etc. Enter Enter BAll ental and lease equipment,which shall Enter Policy Insurance nclude all mobile oNice and storage containers, Number Effective Expiration Coverage Limits as provided by written contract with lessor/lessee Date Date loss payee DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space is required) Pacific Mobile Structures, Inc. is named as additional insured for general liability and loss payee under property insurance maintained by RENTER on any and all, current and future, leased mobile units and equipment. CERTIFICATE HOLDER CANCELLATION Pacific Mobile Structures,Inc. SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Attn:Franci Wolf THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN P.O.Box 1404 ACCORDANCE WITH THE POLICY PROVISIONS. Chehalis,WA 98532 Phone:360.345.1576 Fax:360.748.0578 AUTHORIZED REPRESENTATIVE insurance@pacificmobile.com I V1 03.19.19 REV.Feb..2020