W-9 Request for Taxpayer
Form Give Form to the
(Rev. October 2018) Identification Number and Certification requester. Do not Department of the Treasury
Internal Revenue Service • Go to www.irs.gov/FormW9 for instructions and the latest information. send to the IRS. 1 Name (as shown on your income tax return). Name is required on this line; do not leave this line blank.
BRAUN NORTHWEST, INC.
2 Business name/disregarded entity name, if different from above 3 Check appropriate box for federal tax ciassification of the person whose name Is entered on line 1. Check only one of the 4 Exemptions (codes apply only to following seven boxes.
certain entities, not individuals; se
• s Corporation insiructions on page 3):
Individual/sole proprietor or C Corporation • Partnership L Trust/estate single-member LLC
Exempt payee code (il any)
Print or type. See Specific Instructions on page 3. Limited abilty company. Enter the tax classlication (C-C corporation, S=S corporation, P=Partnership) » Exemption from FATA reporting
anitar 46 he in tot die died from the de appropria box for the a classication of is owner. member LC ar code f any) Other (see instructions) • (Applies to accounts maintained outside the U.S.) 5 Address (number, street, and apt. or suite no.) See instructions. Roquester's name and address (optional) PO BOX 1204/150 NORTH STAR DRIVE
6 City, state, and ZIP code
CHEHALIS, WA 98532
7 List account number(s) here (optional)
Part I Taxpayer Identification Number (TIN)
Enter your TIN in the appropriate box. The TIN provided must match the name given on line 1 to avoid Social security number backup withholding. For individuals, this is generally your social security number (SSN). However, for a resident alien, sole proprietor, or disregarded entity, see the instructions for Part I, later, For other entities, it is your employer identification number (EIN). If you do not have a number, see How to get a TIN. later.
or
Note: If the account is in more than one name, see the instructions for line 1. Also see What Name and Employer identification number Number To Give the Requester for guidelines on whose number to enter.
9.1 1 3 14 4 6 1 9
Part II Certification
Under penalties of perjury, I certify that:
1. The number shown on this form is my correct taxpayer identification number (or I am waiting for a number to be issued to me); and
2. I am not subject to backup withholding because: (a) I am exempt from backup withholding, or (b) I have not been notifled by the Internal Revenue Service (IRS) that I am subject to backup withholding as a result of a failure to report all interest or dividends, or (c) the IRS has notified me that I am no longer subject to backup withholding; and
3. I am a U.S. citizen or other U.S. person (defined below); and
4. The FATA code(s) entered on this form (if any) indicating that i am exempt from FATA reporting is correct.
Certification instructions. You must cross out item 2 above if you have been notified by the IRS that you are currently subject to backup withholding because you have failed to report all interest and dividends on your tax return. For real estate transactions, item 2 does not apply. For mortgage interest paid acquisition or abandonment of secured property, cancellation of debt, contributions to an individual retirement arrangement (IRA), and generally, payments other than interest and dividends, you are not required to sign the certification, but you must provide your correct TIN. See the instructions for Part il, later. 1/2/2024
Gęneral Instructions • Form 1099-DIV (dividends, including those from stocks or mutual funds)
Section references are to the Internal Revenue Code unless otherwise • Form 1099-MISC (various types of income, prizes, awards, or gross noted. proceeds)
Future developments. For the latest Information about developments • Form 1099-B (stock or mutual fund sales and certain other related to Form W-9 and its instructions, such as legislation enacted transactions by brokers) after they were published, go to www.irs.gov/FormW9.
• Form 1099-S (proceeds from real estate transactions)
Purpose of Form • Form 1099-K (merchant card and third party nelwork transactions) An individual or entity (Form W-9 requester) who is required to file an • Form 1098 (home mortgage interest), 1098-E (student loan interest). information return with the IRS must obtain your correct taxpayer identification number (TIN) which may be your social security number • Form 1099-C (canceled debt) (SSN), individual taxpayer identification number (ITIN), adoption taxpaver identification number (ATIN), or emplover identification number • Form 1099-A (acquisition or abandonment of secured property) (EIN), to report on an information return the amount paid to you, or other Use Form W-9 only if you are a U.S. person including a resident amount reportable on an information return. Examples of information alien), to provide your correct TIN. returns include, but are not limited to, the following. If you do not return Form W-9 to the requester with a TIN, you might • Form 1099-INT (interest earned or paid) be subject to backup withholding. See What is backup withholding, later.
Cat. No. 10231X Form W-9 (Rev. 10-2018)
BRAUNOR-01 JDOUGLAS
ACORD®
CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DD/YYYY)
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 REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certal pollcies may require an endorsement. A statement on IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must have ADDITIONAL INSURED provisions or be endorsed this certificate does not confer rights to the certificate holder in lieu of such endorsements).
Hub International Northwest LLC GONEACT
MONE FAX
2 Centerpointe Drive Suite 650 (AIC, No, Ext): (503) 451-7100 L (AC. No): (503) 961-1753 Lake Oswego, OR 97035 AMEs: [email protected]
INSURERS) AFFORDING COVERAGE
NAIC #
INSURERA: Travelers Property Casualty Company of America 25674
INSURED
INSURER B: Travelers Casualty of Connecticut 36170
Braun Northwest, Inc. INSURER C: Travelers Property Casualty Insurance Company P. O. Box 1204 36161
Chehalis, WA 98532 INSURER D:.
INSURER E:
INSURER F:
COVERAGES CERTIFICATE NUMBER:
REVISION NUMBER:
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
INSR
AIR. TYPE OF INSURANCE SD w POLICY NUMBER LICY EI POLICY EXP
X COMMERCIAL GENERAL LIABILITY MIDD/YYYY) (MM/DD/YY LIMITS EACH OCCURRENCE $ 1,000,000
CLAIMS-MADE X OCCUR Y6304W039541TIA23
3/31/2024 3/31/2025 DAMAGE TO RENTED
PREMISES (Ea occurrence). $ 100,000
| MED EXP (Any one person) $ 5,000
PERSONAL & ADV INJURY 1,000,000
GEN'L AGGREGATE LIMIT APPLIES PER:
' POLICY | GENERAL AGGREGATE 2,000,000
LOC
PRODUCTS - COMP/OP AGG 2,000,000
OTHER: STOP GAP
1,000,000
AUTOMOBILE LIABILITY
X i ANY AUTO CO BEEN SINGLE LIMIT $ 1,000,000
AD5W2222772314 3/31/2024 3/31/2025
OWNS ONLY BODILY INJURY (Per person)
AUTOS ONLY BODILY INJURY (Per accident! S
ROPERTY DAMAG
er acciden
A UMBRELLA LIAB X
OCCUR
EACH OCCURRENCE 15,000,000
LACES LAB CLAIMS-MADE
CUP4W0400662314 3/31/2023 3/31/2024 15,000,000
AGGREGATE
DED RETENTION$
FRUTE T
YIN
UB4W0399462314G 3/31/2024 3/31/2025
Mandatory tA RE EXCLUDED CUT N/A E.L. EACH ACCIDENT 1,000,000 'es, describe un |E.L. DISEASE - EA EMPLOYEE S 1,000,000 - SCRIPTION OF OPERATIONS bel 1,000,000
B Garage & Dealers AD5W2222772314 373172025 Per Locate POLICY MIT. 8 3/31/2024 $00,000
Operations of the named insured in a verdas at te lay torn, coins, any deals mere space l reques Operations of the named insured in accordance with the policy terms, conditions, and exclusions. Re: 501 Sumner St. Honolulu, HI 96814
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE .R. Braun NW, Inc./Braun NW, Inc./JLT Holding, LLO ACCORDANCE THE POL PROSTICE WILL BE DELIVERED IN .R. Braun NW, Inc./Braun NW, Inc./JLT Holding, LL
PO Box 1204
Chehalis, WA 98532 AUTHORIZED REPRESENTATIVE
Eng tinner
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