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HomeMy WebLinkAboutCSRMA WC Program Member��CC>RD® l `./ CERTIFICATE OF LIABILITY INSURANCE DATE (MMIDD/YYYY) 6/26/2020 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 Alliant Insurance Services, Inc. 100 Pine Street, 11 th Floor San Francisco CA 94111 CONTACT NAME: Thary OU PHONE FAX Ic No): 415-874-4813 Ic No Ext): 415-403-1400 AIC, LAIC, noDRess: tou@alliant.com INSURER(S) AFFORDING COVERAGE NAIC # INSURER A: Safety National Casualty 15105 EACH OCCURRENCE $ INSURED WESTBAY-02 INSURER B: CSRMA WC Program Member: West Bay Sanitary District wsuRERc: GEN'L AGGREGATE LIMIT APPLIES PER: POLICY PRO LOC JECT OTHER: 500 Laurel St INSURER D: INSURER E : Menlo Park CA 94025 INSURER F : nnVFROnFS CERTIFICATE NUMBER: 612444965 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 ADDLSUER Town of Los Altos Hills POLICY NUMBER POLICY EFF MMIDDIYYYY POLICY EXP MM/DDIYYYY LIMITS 26379 Fremont Road COMMERCIAL GENERAL LIABILITY CLAIMS -MADE 1-1OCCUR EACH OCCURRENCE $ D-A-MAGETO RETE PREMISES (Ea occur ence) $ MED EXP (Any one person) $ PERSONAL & ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: POLICY PRO LOC JECT OTHER: GENERAL AGGREGATE $ PRODUCTS -COMP/OP AGG $ $ AUTOMOBILE LIABILITY ANY AUTO OWNED SCHEDULED AUTOS ONLY AUTOS HIRED NON -OWNED AUTOS ONLY AUTOS ONLY f 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 $ $ A WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANYPROPRIETOR/PARTNER/EXECUTIVE YINE.L. OFFICER/MEMBEREXCLUDED? F --]N/A (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below SP4063068 7/1/2020 7I1I2021 X PER OTH- STATUTE ER EACH ACCIDENT $ 1,000,000 E.L. DISEASE - EA EMPLOYEE $ 1,000,000 E.L. DISEASE " POLICY LIMIT $ 1,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space Is required) This certificate is issued for evidence only. CGRTIFIrATt= Nf]I ni=p CANCELLATION ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Town of Los Altos Hills ACCORDANCE WITH THE POLICY PROVISIONS. Attn: Public Works Director AUTHORIZED REPRESENTATIVE 26379 Fremont Road Los Altos Hills CA 94022 ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD OF COVERAGE E (MM/DD/YYYY)CERTIFICATE DAT6/26/2020 PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF EVIDENCE ONLY AND CONFERES NO RIGHTS UPON THE CERTIFICATE HOLDER, THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR Alliant Insurance Services, Inc. NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE MEMORANDUM(S) OF COVERAGE BELOW. 100 Pine Street, 11th Floor THIS CERTIFICATE OF COVERAGE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE San Francisco CA 94111 ISSUING COVERAGE PROVIDER, AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. GENERAL LIABILITY IMPORTANT: IF THE CERTIFICATE HOLDER IS AN ADDITIONAL COVERED PARTY, THE MEMORANDUM OF COVERAGE MUST BE ENDORSED. A STATEMENT ON THIS CERTIFICATE EACH OCCURRENCE $ DOES NOT CONFER RIGHTS TO THE CERTIFICATE HOLDER IN LIEU OF SUCH ENDORSEMENT(S). IMPORTANT: IF SUBROGATION IS WAIVED, SUBJECT TO THE TERMS AND CONDITIONS OF THE NAMED COVERED PARTY CSRMA WC Program Member: West Ba Sanitary District Y rY 500 Laurel St Menlo Park CA 94025 MEMORANDUM(S) OF COVERAGE AN ENDORSEMENT MAY BE REQUIRED. A STATEMENT ON THE CERTIFICATE DOES NOT CONFER RIGHTS TO THE CERTIFICATE HOLDER IN LIEU OF SUCH ENDORSEMENT(S). PROGRAM AFFORDING COVERAGE A: C.S.R.M.A. CLAIMS MADE ❑ OCCUR B: C: COVERAGES THIS IS TO CERTIFY THAT THE COVERAGE IS AFFORDED TO THE ABOVE NAMED MEMBER, AS PROVIDED BY THE MEMORANDUM(S) OF COVERAGE, FOR THE PERIOD SHOWN BELOW, NOT WITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN. THE COVERAGE AFFORDED BY THE PROGRAM DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS, AND CONDITIONS OF SUCH MEMORANDUM(S) OF COVERAGE. THE FOLOWING COVERAGE IS IN EFFECT. JPA LTR TYPE OF COVERAGE MEMORANDUM NUMBER COVERAGE EFFECTIVE DATE (MMIDD/YY) COVERAGE EXPIRATION. DATE (MM/DD/YY) LIMITS GENERAL LIABILITY EACH OCCURRENCE $ COMMERCIAL GENERAL LIABILITY FIRE DAMAGE (Any one fire) $ CLAIMS MADE ❑ OCCUR MED EXPENSE (Any one person) $ PERSONAL & ADV INJURY $ GENERAL AGGREGATE $ GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ MEMOPROJECT LOC A ANDUM El AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ ANY AUTO (Ea accident) $ ALL OWNED AUTOS SCHEDULED AUTOS HIRED AUTOS NON -OWNED AUTOS A WORKERS' COMPENSATION AND CSWC WBSD 2021 1 7/1/2020 7/1/2021 WC X OTHER STATUTORY EMPLOYERS LIABILITY LIMITS $750,000 ANY PROPRIETOR/PARTNER/ EXECUTIVE/OFFICER/MEMBER E.L. EACH ACCIDENT $ EXCLUDED? E.L. DISEASE — EA EMPLOYEE $ IF YES, DESCRIBED UNDER SPECIAL E.L. DISEASE—POLICY LIMIT $ PROVISION BELOW OTHER OTHER DESCRIPTION OF OPERATIONS/LOCATIONSfVEHICLES/EXCLUSIONS ADDED BY ENDORSEMENTISPECIALIPROVISIONS This certificate is issued for evidence only. CERTIFICATE HOLDER CANCELLATION Town of Los Altos Hills Attn: Public Works Director 26379 Fremont Road Los Altos Hills CA 94022 SHOULD ANY OF THE ABOVE DESCRIBED MEMORANDUM(S) OF COVERAGE BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE MEMORANDUM(S) OF COVERAGE PROVISIONS. AUTHORIZED REPRESENTATIVE