SH16-007 NW Assessment Prof. Agreement

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AC " CERTIFICATE OF LIABILITY INSURANCE I DATE(MM/DDIYYYY) `..� 03/23/2016 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 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: Trust Risk Management Services, Inc PHONE (A/C, o, Ext): 877.637.9700 FAX (AIC, No): 877.251.5111 Trust Risk Management Services, Inc. 1791 Paysphere Circle EMAChicago, IL 60674 ADDRESS: info trustrms,com INSURER(S) AFFORDING COVERAGE NAIC # POLICY NUMBER INSURER A: ACE American Insurance Company 22667 (MM/DD/YYYY) INSURED INSURER B: Dr. Monica Pilarc 4500 9th Ave NE Ste 300 Seattle, WA 98105 INSURER C: 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. INSR ADDL SUB POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSR I WVD POLICY NUMBER (MM/DD/YYYY) (MM/DD/YYYY) LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ CLAIMS MADE❑OCCUR DAMAGE TO RENTED $ PREMISES (Ea occurrence) MED EXP (Any one person) $ PERSONAL 8 ADV INJURY $ L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ PR POLICY ❑JECOTF1LOC M'OTHER: PRODUCTS—COMP/OP AGG$ AUTOMOBILE LIABILITY CEaOMBINED M. ccident SINGLE LIMIT $ BODILY INJURY (Per Person) $ ANY AUTO ALL OWNED SCHEDULED AUTOS AUTOS $ BODILY INJURY (Per accident HIRED AUTOS ANO -OWNED PROPERTY DAMAGE $ Per accident UMBRELLALIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS -MADE AGGREGATE $ DED RETENTION $ WORKERS COMPENSATION AND EMPLOYERS LIABILITY y I N PER 0TH- $ STATUTE ER E.L.EACH ACCIDENT $ ANY PROP RIETOR/PARTNER/EXEC UTIVE NIA E.L. DISEASE -EA EMPLOYEE $ OFFICER/MEMBER EXCLUDED? (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below $ E.L. DISEASE -POLICY LIMIT A Psychologist's Professional Liability Retroactive Date 06/07/2002 Y 58622353445 06/07/2015 06/07/2016 Each Incident Annual $1,000,000 $3,000,000 Aggregate DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) CERTIFICATE HOLDER CANCELLATION Additional Insured Kittitas County 205 W 5th Avenue Ste 108 Ellensburg, WA 98926 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE ACORD 25 (2014/01) ©1988-2014 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD