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HomeMy WebLinkAboutCertificate of InsuranceCERTIFICATE OF LIABILITY INSURANCE DATE (MMIDO/YYYY) 1 TYPEOPINSURANCE 09/0212021 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFER$ 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 ls an ADDITIONAL INSURED, the pollcy(los) 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 _gONTACT n k C Q. Mark StateFarm State Farm PHONE 70-7100 Na 408-370-7009 _�h • Mark Chapman, Agent OW. , mark@�nW�k insurance. S. com 250 E Hamilton Ave, Ste B INSU ------- Campbell, CA 96008 -Lqs LgRm& State Farm Mutual Automobile Insurance Company 25178 INSURED INSURER 8 1 Statcomm Inc. INSURSRC: 939mC San Rafael Ave INSURER D: Mountain View, CA 94043 jqSUR!LR_E INSURER F: %%jVCMAkar-5 Ult!N I II-IUA I I- N1 JREIIAI=W' All k3 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. I -TR TYPEOPINSURANCE 1) SUBIR v4vo POLICY NUMBER MO_WY r;E�lf 0(�__ POLICY E)y YY Y, (AMIDDY1 Yyyy, . . ...... ... LIMITS 26379 Fremont Road Los Altos Hills CA 94022 1 _775 COMMERCIAL GENERAL LIABILITY CLAIMS -MADE E] OCCUR EACH OCCURRENCE _bAM_A_dE­TO_RENTED MED EXPAny one arson . . ......... GEN'I. AGGREGATE LIMIT APPLIES PER: PRO. POLICY JECT I LOC GENERAL A S. OTHER: A AUTOMOBILE LIABILITY ANYAUTO OWNED SCHEDULED AUTOS ONLY AUTOS HIRED -NON-OWNED AUTOS ONLY AUTOS ONLY Y Y 2241457 -A06 -05K 07/06121121 07105/2022 ED SINGLE LIMIT_ 0 jOaMOINid n�t $ 1,000,000 BODILY INJURY (Per'Person) $ BODILY INJURY (Per accident) $ PROPERTY (Per accident) _ — $ -EXCESS UMBRELLA LIAR OCCUR _§ACH OCCURRENCE --- LIAR .1 CLAIMS -MADE AGGREGATE $ ED RETENTION $ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y/N ANY PROPRIETORIPARTNERIEXECUTIVE r --j OFFICERIMEMBER EXCLUDED? L -i (Mandatory In NH) S, If describe under DESCRIPTION OF OPERATIONS below N/A I PER __F —IOTH- _j98�T_Q'L1�_L_j_LR_ E.I., EACH ACCIDENT_ ........... .LL. DISEASE - FA EMPLOYEE _� . ...... . $ E.L. DI$EASE-PQLICY LIMIT $ DESCRIPTION OF OPERATIONS I LOCATIONS / VEHICLES (ACORD 101, Additional RoMarks Schedule, May be attached If more space is required) 30 Day Written Notice OF Cancellation to be mailed to Additional Insured. The Town of Los Altos Hills, Its elective and appointed officers, employees and volunteers are additional Insureds, L.r_xTfi-it.;iA i F. Htji_i ji-w e kle'Cl I A 'rle%Kl 011988-2016 ACORD CORPORATION, All rights reserved. ACORD 26 (2016/03) The ACORD name and logo are registered marks of ACORD 1001486 132849.12 03-16-2016 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 _Z;TH70R1Z SENTATIVE 26379 Fremont Road Los Altos Hills CA 94022 1 _775 ... 011988-2016 ACORD CORPORATION, All rights reserved. ACORD 26 (2016/03) The ACORD name and logo are registered marks of ACORD 1001486 132849.12 03-16-2016 STATINC-OR RAIPATRAA ACOR®� CERTIFICATE OF LIABILITY INSURANCE `--� DATE(MM/DD/YYYY) 9/9/2021 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 PRODUCER Opendorsement(s). NAMEACT Michele Costa Bozzuto & Associates Insurance ServicesCNtJa, 34 S 2nd Street Campbell, CA 95008 Ext : (408) 680-0217 FAX No): E-MAIL michelec@dbinsurance.com INSURERS AFFORDING COVERAGE NAIC # 10/1/2021 INSURER A: Everest Indemnity Insurance Company 10851 DAMAGE TO RENTED 100,000 PREMISES (Ea occurr ce INSURED INSURER B: Cypress Insurance Company CA 10855 INSURER C: Ohio Securit Insurance Company 24082 Statcomm Inc. INSURER D: 939C San Rafael Ave. Mountain View, CA 94043 INSURER E INSURER F: AUTOMOBILE CnVFRAGFA CF_RTIFICATF_ NLJMRFR- RFVI_¢InN NnMRFR. 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 TYPE OF INSURANCE ADDINSDL SUBR WVD POLICY NUMBER POLICY EFF MM POLICY EXPLTR LIMITS A X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE X OCCUR X 51GLOO5784-201 10/1/2020 10/1/2021 EACH OCCURRENCE 1,000,000 DAMAGE TO RENTED 100,000 PREMISES (Ea occurr ce MED EXP (Any oneperson) 5,000 X Prof.Poll Limited PERSONAL &ADV INJURY 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: ]POLICY ® TECT [:] LOC OTHER: GENERAL AGGREGATE 2,000,000 PRODUCTS - COMP/OP AGG 2,000,000 AUTOMOBILE LIABILITY ANY AUTO OWNED SCHEDULED AUTOS ONLY AUTOS AUTOS ONLY AUTOS ONL� COMBINED SINGLE LIMIT Ea accident $ BODILY INJURY Perperson) $ INJURY Per accident -BODILY PPe�acciden DAMAGE A UMBRELLA LIAR EXCESS LIAB X OCCUR CLAIMS -MADE 51CCO02025-201 10/1/2020 10/1/2021 EACH OCCURRENCE 7,000,000 X AGGREGATE 7,000,000 DED I is RETENTION $ 10,000 B WORKERS COMPENSATION AND EMPLOYERS' LIABILITY OFFICERO� RIETO R EXCLUDR E ECUTIVE Y� (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below N / A STWC 142798 1011/2020 10/112021 X STATUTE ETH - E.L. EACH ACCIDENT 1,000,000 E.L. DISEASE - EA EMPLOYEE $ 1,000,000 E.L. DISEASE - POLICY LIMIT 1,000,000 C Property BKS56535161 10/1/2020 10/1/2021 BPP/Ded 295,652 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space Is required) The Town of Los Altos Hills, its elective and appointed officers, employees, and volunteers are included as an additional insured on General Liability policy per the attached endorsements. CERTIFICATE HOLDER CANCFI I ATION ACORD 25 (2016/03) @ 1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Town of Los Altos Hills TownFremont Road THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Los Altos Hills, CA 94022 AUTHORIZED REPRESENTATIVE .Grtuda $lfla ACORD 25 (2016/03) @ 1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD POLICY NUMBER:51GL005784-201 COMMERCIAL GENERAL LIABILITY CG 20 10 04 13 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - OWNERS, LESSEES OR CONTRACTORS - SCHEDULED PERSON OR ORGANIZATION This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Name Of Additional Insured Person(s) Or Organizations Locations Of Covered Operations Blanket where required by written contract 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 B 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. 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. CG 20 10 04 13 0 Insurance Services Office, Inc., 2012 Page 1 of 2 C. 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 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. Page 2 of 2 © Insurance Services Office, Inc., 2012 CG 20 10 04 13 POLICY NUMBER:51GL005784-201 COMMERCIAL GENERAL LIABILITY CG 20 37 0413 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - OWNERS, LESSEES OR CONTRACTORS - COMPLETED OPERATIONS This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE PART 3�3,`r=17 Name Of Additional Insured Person(s) Or Organization(s) Location And Description Of Completed Operations Blanket where required by written contract 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. 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. CG 20 37 04 13 0 Insurance Services Office, Inc., 2012 Page 1 of 1