HomeMy WebLinkAboutCertificate of InsuranceAC " R" CERTIFICATE OF LIABILITY INSURANCE
DATE(MM/DD/YYYY)
07/08/2022
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
Hiscox Inc. d/b/a/ Hiscox Insurance Agency in CA
520 Madison Avenue
32nd Floor
CONTACT
NAME:
PHONE FAX
(AIC,
/C No Ext): (ggg ) 202-3007 A/c No
ADDRESS: contact@hiscox.com
INSURER(S)AFFORDING COVERAGE
NAIC #
New York, New York 10022
INSURERA: Hiscox Insurance Company Inc
10200
MED EXP (Any one person) $ 5,000
INSURED
Tiffany Dell Aquila Miller Architect
2327 Catalina Ave
INSURERB:
GEN -L AGGREGATE LIMIT APPLIES PER:
X POLICY 1 PRO JECT ❑ LOC
OTHER:
INSURERC:
PRODUCTS - COMP/OPAGG $ S/TGen. Agg.
$
Vista, CA 92084
INSURER D :
INSURER E:
INSURER F :
COMBINED SINGLE LIMIT $
Ea accident
BODILY INJURY (Per person) $
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 LTR
TYPE OF INSURANCE
ADDDL
SUBD
POLICY NUMBER
MM/DDNYYY
MM/DD�YY
LIMITS
A
X COMMERCIAL GENERAL LIABILITY
CLAIMS -MADE F OCCUR
P100.190.143.4
04/01/2022
04/01/2023
EACH OCCURRENCE $ 1,000,000
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:
X POLICY 1 PRO JECT ❑ LOC
OTHER:
GENERAL AGGREGATE $ 2,000,000
PRODUCTS - COMP/OPAGG $ S/TGen. Agg.
$
AUTOMOBILE
LIABILITY
ANY AUTO
ALL OWNED SCHEDULED
AUTOS AUTOS
NON -OWNED
HIRED AUTOS AUTOS
COMBINED SINGLE LIMIT $
Ea accident
BODILY INJURY (Per person) $
BODILY INJURY $
Per accident
( )
PROPERTY DAMAGE
Per accident $
UMBRELLALIAB
EXCESS LIAB
OCCUR
CLAIMS -MADE
EACH OCCURRENCE $
AGGREGATE $
DED RETENTION $
$
WORKERS COMPENSATION
AND EMPLOYERS' LIABILITY Y / N
ANYPROPRIETOR/PARTNER/EXECUTIVEE.L.
OFFICER/MEMBER EXCLUDED? F—]
(Mandatory in NH)
If yes, describe under
DESCRIPTION OF OPERATIONS below
N/A
PER OTH-
STATUTE ER
EACH ACCIDENT $
E.L. DISEASE - EA EMPLOYEE $
E.L. DISEASE - POLICY LIMIT 1 $
DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required)
CERTIFICATE HOLDER CANCELLATION
Town of Los Altos Hills
26379 Fremont Road
Los Altos Hills, CA 94022
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
U 1988-2015 ACORD CORPORATION. All rights reserved.
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