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HomeMy WebLinkAboutCertificate of InsuranceCERTIFICATE OF LIABILITY INSURANCE DATE(MM06/18/120192019 YY) 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(les) 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 - AOn Risk Seryl C2S Northeast, Inc, New York NY Office CONTACT NAME; (A/c No. Ext): (866) 283-7122 jac No ): (800) 363-0105 One Liberty Plaza 165 Broadway, Suite 3201 E-MAIL ADDRESS: New York NY 10006 USA EACH OCCURRENCE $1,000,000 INSURER(S) AFFORDING COVERAGE NAIC # INSURED INSURERA: National union Fire Ins CO of Pittsburgh 19445 Cellco Partnership dba Verizon wireless 1095 Avenue of the Americas New York NY 10036 USA INSURER B: New Hampshire insurance Company 23841 INSURER C: AIU Insurance Company p y 19399 INSURERD: American Home Assurance Co. 19380 MED EXP (Any one person) $10 , 000 INSURER E: Illinois National insurance CO 23817 X XCU Coverage is Included INSURER F: COVERAGES GERTiFiCAIt NUMBER: o/UU(titl ii21 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. Limits shown are as requested INSINSR LTR TYPE OF INSURANCE D INSD S B WVD POLICY NUMBER POLICY MMIDD/YYYY POLICY EXP MMIDDIYYYY LIMITS A X COMMERCIAL GENERAL LIABILITY GL6412251 EACH OCCURRENCE $1,000,000 CLAIMS-MADEX❑ OCCUR DAMAGE TO RENTED $2,000,000 PREMISES Ea occurrence MED EXP (Any one person) $10 , 000 X XCU Coverage is Included PERSONAL &ADV INJURY $1,000,000 GEN'LAGGREGATE LIMITAPPLIES PER: GENERAL AGGREGATE $2,000,000 X POLICY PRO- JECT LOC PRODUCTS - COMP/OPAGG $2,000,000 OTHER: AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea accident BODILY INJURY ( Per person) ANYAUTO OWNED SCHEDULED AUTOS ONLY AUTOS HIREDAUTOS NON -OWNED ONLY AUTOS ONLY BODILY INJURY (Per accident) PROPERTY DAMAGE Per accident UMBRELLA LIAB OCCUR EACH OCCURRENCE EXCESS LIAB CLAIMS -MADE AGGREGATE DED RETENTION B D WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y / N ANY PROPRIETOR / PARTNER / EXECUTIVE OFFICER/MEMBER EXCLUDED N 1 A WC014649148 AOS WC014649146 06/30/2019 06/30/2019 06/30/2020X 06/30/2020 PER 107- STATUTE ER E.. EACH ACCIDENT L $1,000,000 E.L. DISEASE -EA EMPLOYEE $1,000,000 (Mandatory In NH) If yes, describe under DESCRIPTION OF OPERATIONS below CA E.L. DISEASE -POLICY LIMIT $1,000,000 _F DESCRIPTION OF OPERATIONS / LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached If more space is required) Named insured also includes: GTE Mobilnet of California Limited Partnership d/b/a verizon Wireless. Re: wireless facility: Los Altos Hills Civic. Town of Los Altos Hills, its elected and apppointed officials, employees, agents, contractors, consultants, and volunteers are included as additional insureds as required by written contract except for workers compensation and employers liability. CERTIFICATE HOLDER CANCELLATION ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD Iq 00 0 0 LO LO O Z d R U 4= Q 0) L) SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Town Of LOS Altos Hills 26379 Freemont Road AUTHORIZED REPRESENTATIVE Losa Altos Hills CA 94022 USA (� ;��(,�lQ `/��/� �� t-.>4Gvm gp,01 e/ 2GL24%G�c�d c../�vr'�r` ro JL ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD Iq 00 0 0 LO LO O Z d R U 4= Q 0) L) AGENCY CUSTOMER ID: 570000027366 p REMARKS p ® �RKS + LOC #: �'`.---- ADDITIONAL REMASCHEDULE Page _ of _ AGENCY Aon Risk Services Northeast, Inc. NAMED INSURED cellco Partnership dba verizon wireless POLICY NUMBER See certificate Number: 570076871121 CARRIER See certificate Number: 570076871121 NAIC CODE EFFECTIVE DATE: ADDITIONAL REMARKS THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, FORM NUMBER: ACORD 25 FORM TITLE: Certificate of Liability Insurance INSURER(S) AFFORDING COVERAGE MAIC # INSURER TYPE OF INSURANCE INSURER SUBR W VD INSURER POLICY EFFECTIVE DATE MM/DD/YYY INSURER LIMITS ADDITIONAL POLICIES If a policy below does not include limit information, refer to the corresponding policy on the ACORD certificate form for policy limits. INSR LTR TYPE OF INSURANCE ADDL INSD SUBR W VD POLICY NUMBER POLICY EFFECTIVE DATE MM/DD/YYY POLICY EXPIRATION DATE MM/DD/Y LIMITS WORKERS COMPENSATION c N/A wc014649149 NY 06/30/2019 06/30/2020 E N/A wc014649144 FIL 06/30/2019 06/30/2020 B N/A wc014649145 MA,ND,OH,WI,WY 06/30/2019 06/30/2020 B N/A wc014649147 NJ,TX,VA 06/30/2019 06/30/2020 ACORD 101 (2008/01) © 2008 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD