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HomeMy WebLinkAboutCertificate of Insurance 20181 0 CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DDIYYYY) 6/26/2018 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 p Bolton & Com an CONTACT NAME: 3475 E. Foothill Blvd., Suite 100 Pasadena, CA 91107 PHONE FAX A/CANo Ext): 626 799-7000 AIC No): 626 583-2117 ADDRESS: INSURERS AFFORDING COVERAGE NAIC # ✓ INSURERA: Old Republic General Insurance Corp24139 www.boltonco.com 0008309 INSURED O'Grady Paving, Inc. DBA: A & D Trucking; Best Equipment Rentals 2513 Wyandotte Street INSURER B : Starr Indemnity & Liability Company 38318 INSURERC: Underwriters at Lloyd's, London INSURER D : Mountain View CA 94043 INSURERE: INSURER F: COVERAGES CERTIFICATE NUMBER: 42809021 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 LTR TYPE OF INSURANCE ADDL INSD SUBR WVD POLICYNUMBER POLICY EFF MMIDD/YYYY POLICY EXP MM/DDIYYYY LIMITS A ✓ COMMERCIAL GENERAL LIABILITY ✓ AlCG44181800 7/1/2018 7/1/2019 EACH OCCURRENCE $1,000,000 CLAIMS -MADE F✓ OCCUR DAMAGE S(RENTED PREMISES Ea occurrence) $ 100,000 MED EXP (Any one person) $ 5,000 Deductible: $5,000/Occurrence PERSONAL &ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERALAGGREGATE $2,000,000 RO POLICY ✓� ECT LOC PRODUCTS - COMP/OP AGG $2,000,000 $ OTHER: A AUTOMOBILE LIABILITY AlCA44181800 7/1/2018 7/1/2019 EaaBINEDtSINGLELIMIT $1,000,000 ✓ BODILY INJURY (Per person) $ ANY AUTO OWNED SCHEDULED AUTOS ONLY AUTOS BODILY INJURY (Per accident) $ ✓ FIR ER Peoa cidenDAMAGE $ HIRED NON-WND AUTOS ONLY ✓ AUU OS ONLY Com reh/Collision Ded. $1,000 B UMBRELLALIAB / OCCUR 1000585182181 7/1/2018 7/1/2019 EACH OCCURRENCE $10,000,000 AGGREGATE $ 10,000 000 EXCESS LIAB CLAIMS -MADE DED I I RETENTION $0 Prod -Comp Ops Agg $10,000,000 A WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y/ N ANYPROPRIETOR/PARTNER/EXECUTIVE I Y OFFICER/MEMBEREXCLUDED7 N / A ✓ A1CW44181800 7/1/2018 7/1/2019 ,/ STATUTE EORH E.L. EACH ACCIDENT $ 1,000,000 E.L. DISEASE - EA EMPLOYEE $1,000.000 (Mandatory In NH) If yes, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT 1 $1 000 000 C Pollution Liability PGIARK0873600 7/1/2018 7/1/2019 Limit: $1,000,000; Deduct: $10,000 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) GL Additional Insured applies per CG20100413 & CG20370413 attached, only if required by written contract/agreement. GL Primary & Non -Contributory Wording applies per CGENGN00290906 attached. WC Waiver of Subrogation apply per the WC9903150906 attached. Re: Job #17109 - 2017 Pavement Rehabilitation and Drainage Improvement Project. Additional Insured(s): Town of Los Altos Hills, its Officials and Employees. CERTIFICATE HOLDER CANCELLATION Town of Los Altos Hills Tow TowAllen Chen, Public Works Director Attn:Fremont Road SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Los Altos Hills, CA 94022 AUTHORIZED REPRESENTATIVE Chau Tran ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD 92809021 1 18-19 WC, Auto, GL, XS, POLL I Mary Massinger 1 6/26/2018 5:00:58 PM (PDT) I Page 1 of 6 POLICY NUMBER: AlCG44181800 COMMERCIAL GENERAL LIABILITY CG 20 37 0413 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. '� • • • • U11• • • MCA • A , • This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE PART SCHEDULE Name Of Additional Insured Person(s) Or Organizations Location And Description Of Completed Operations Any person or organization to whom or to which you are obligated by written contract/agreement or by the issuance or existence of a written permit executed prior to a loss. Information required to complete this Schedule, if not shown above, will be shown in the Declarations. A. Section II — Who Is An Insured is amended to include as an additional insured the person(s) or organization(s) shown in the Schedule, but only with respect to liability for "bodily injury" or "property damage" caused, in whole or in part, by "your work" at the location designated and described in the Schedule of this endorsement performed for that additional insured and included in the "products -completed operations hazard". However: 1. The insurance afforded to such additional insured only applies to the extent permitted by law; and 2. If coverage provided to the additional insured is required by a contract or agreement, the insurance afforded to such additional insured will not be broader than that which you are required by the contract or agreement to provide for such additional insured. CG 20 37 04 13 B. With respect to the insurance afforded to these additional insureds, the following is added to Section III — Limits Of Insurance: If coverage provided to the additional insured is required by a contract or agreement, the most we will pay on behalf of the additional insured is the amount of insurance: 1. Required by the contract or agreement; or 2. Available under the applicable Limits of Insurance shown in the Declarations; whichever is less. This endorsement shall not increase the applicable Limits of Insurance shown in the Declarations. © Insurance Services Office, Inc., 2012 92809021 1 18-19 WC, Auto, GL, XS, POLL I Mary Massinger 1 6/26/2018 5:00:58 PM (PDT) I Page 2 of 6 Page 1 of 1 POLICY NUMBER: A1CG44181800 COMMERCIAL GENERAL LIABILITY CG 20 10 0413 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Name Of Additional Insured Person(s) Or Organization(s) Locations Of Covered Operations Any person or organization to whom or to which you are obligated by written contractlagreement or by the issuance or existence of a written permit executed prior to a loss. Information required to complete this Schedule, if not shown above, will be shown in the Declarations. A. Section II — Who Is An Insured is amended to include as an additional insured the person(s) or organization(s) shown in the Schedule, but only with respect to liability for "bodily injury", "property damage" or "personal and advertising injury" caused, in whole or in part, by: 1. Your acts or omissions; or 2. The acts or omissions of those acting on your behalf; in the performance of your ongoing operations for the additional insured(s) at the location(s) designated above. However: 1. The insurance afforded to such additional insured only applies to the extent permitted by law; and 2. If coverage provided to the additional insured is required by a contract or agreement, the insurance afforded to such additional insured will not be broader than that which you are required by the contract or agreement to provide for such additional insured. CG 20 10 04 13 B. With respect to the insurance afforded to these additional insureds, the following additional exclusions apply: This insurance does not apply to "bodily injury" or "property damage" occurring after: 1. All work, including materials, parts or equipment furnished in connection with such work, on the project (other than service, maintenance or repairs) to be performed by or on behalf of the additional insured(s) at the location of the covered operations has been completed; or 2. That portion of "your work" out of which the injury or damage arises has been put to its intended use by any person or organization other than another contractor or subcontractor engaged in performing operations for a principal as a part of the same project. © Insurance Services Office, Inc., 2012 92809021 1 18-19 WC, Auto, GL, XS, POLL I Mary Massinger 1 6/26/2018 5:00:58 PM (PDT) I Page 3 of 6 Page 1 of 2 C. With respect to the insurance afforded to these additional insureds, the following is added to Section 111— Limits Of Insurance: If coverage provided to the additional insured is required by a contract or agreement, the most we will pay on behalf of the additional insured is the amount of insurance: 1. Required by the contract or agreement; or Page 2 of 2 2. Available under the applicable Limits of Insurance shown in the Declarations; whichever is less. This endorsement applicable Limits of Declarations. © Insurance Services Office, Inc., 2012 92809021 1 18-19 WC, Auto, GL, XS, POLL I Mazy Massinger 1 6/26/2018 5:00:58 PM (PDT) I Page 4 of 6 shall not increase the Insurance shown in the CG 20 10 04 13 CHANGES ADDITIONAL INSURED PRIMARY WORDING SCHEDULE THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. THIS ENDORSEMENT MODIFIES INSURANCE PROVIDED UNDER THE FOLLOWING: COMMERCIAL GENERAL LIABILITY COVERAGE FORM Name of Additional Insured Person(s) Location(s) of Covered Operations Or Organization(s): Where required by written contract. Information required to complete this Schedule, if not shown above, will be shown in the Declarations. The insurance provided by this endorsement is primary insurance and we will not seek contribution from any other insurance of a like kind available to the person or organization shown in the schedule above unless the other insurance is provided by a contractor other than the person or organization shown in the schedule above for the same operation and job location. If so, we will share with that other insurance by the method described in paragraph 4.c. of Section IV — Commercial General Liability Conditions. All other terms and conditions remain unchanged. Named Insured O'Grady Paving, Inc. Policy Number AlCG44181800 Endorsement No. Policy Period 07/01/2018 Endorsement Effective Date: Producer's Name: OLD REPUBLIC CONSTRUCTION INSURANCE AGENCY, INC. Producer Number: 7000 AUTHORIZED REPRESENTATIVE CG EN GN 0029 09 06 92809021 1 18-19 WC, Auto, GL, XS, POLL I Mary Massinger 1 6/26/2018 5:00:58 PM (PDT) I Page 5 of 6 DATE OLD REPUBLIC GENERAL INSURANCE CORPORATION WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. THIS ENDORSEMENT MODIFIES INSURANCE PROVIDED UNDER THE FOLLOWING: WORKERS' COMPENSATION AND EMPLOYERS' LIABILITY INSURANCE We have the right to recover our payments from anyone liable for an injury covered by this policy. We will not enforce our right against the person or organization named in the Schedule. This agreement applies only to the extent that you perform work under a written contract that requires you to obtain this agreement from us. This agreement shall not operate directly or indirectly to benefit anyone not named in the Schedule. Schedule WHEN REQUIRED BY WRITTEN CONTRACT. The premium charge for this endorsement is $0.00 Named Insured O'Grady Paving, Inc. Policy Number Al CW44181800 Endorsement No. 000 Policy Period 07/01/2018 to Endorsement Effective Date: Producer's Name: OLD REPUBLIC CONSTRUCTION INSURANCE AGENCY, INC. Producer Number: 0000007000 AUTHORIZED REPRESENTATIVE DATE WC 99 03 15 (09/06) 42809021 1 18-19 WC, Auto, GL, XS, POLL I Mary Massinger 1 6/26/2018 5:00:58 PM (PDT) I Page 6 of 6