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----*1 DATE(MMIDD/YYYY) ACORCI CERTIFICATE OF LIABILITY INSURANCE ki..../ 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: Insurance Agent/Broker Name IA/C.No.EMI: WNE C,No). Insurance Agent/Broker Street Address or P.O.Box E-MAILSS: City,State,and Zip Code INSURERS)AFFORDINGCOVERAGE NAICN Contact and Phone Number INSURER A: Name of Insurance Enter NAIC# INSURED INSURER B: Name of Insurance Company(if applicable) Enter NAIC aY Customer Name INSURER C: Name of Insurance Company(if applicable) Enter NAIC M Customer Street Address or P.O.Box INSURER D: _ 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) (efYYYY) LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 Ax CLAIMS-MADE X OCCUR X PREMISES(Ea occurrence) $ 100,000 Enter Policy Number Ente nter MED EXP(Any one person) $ N/A Effie xpiration t Date PERSONAL&ADV INJURY $ 1,000,000 GE 'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 X POLICY PRO- LOC ` PRODUCTS-COMP/OP AGG $ 1,000,000 OTHER: •4tti, $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT _$ (Ea accident) ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS HIRED NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY AUTOS ONLY0° (Per accident) $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ _- EXCESS LIAB CLAIMS-MADE `e AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION PER ERR- AND EMPLOYERS'LIABILITY STATUTE ER YIN OFFICERJM MBER EXCLUDED? /EXECUTIVE E.L.EACH ACCIDENT $ OFFICER/MEMBEREXCLUDN/A (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT S Other:Property,Equipment,Inland Marine,etc. Enter Enter Insurance BAll rental and lease equipment,which shall Colt Enter Policy include all mobile office and storage containers, Number Effective Expiration Coverage Limits as provided by written contract with lessor/lessee Date Date loss payee DESCRIPTION OF OPERATIONS I LOCATIONS/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 I nsurance@pacificmobile.com V1 03.19.19 REV Feb..2020