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AC"Ror CERTIFICATE OF LIABILITY INSURANCE
DATE(MM/DD/YYYY)
INDICATED, NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF
08/22/2022
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(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
Willis Towers Watson Midwest, Inc.
c/o 26 Century Blvd
P .O.Box 305191
Nashville, TN 372305191 USA
CONTACT Willis Towers Watson Certificate Center
NAME: __
PHONE 1-877-945-7378
N A/C No; 1-888-467-2378
E-MAIL
ADDRESS: certificates@willis.com
INSURERS AFFORDING COVERAGE NAIC #
INSURERA: Zurich American Insurance Company 16535
INSURED
MP Nexlevel of California, Inc.
INSURER B: AXIS Surplus Insurance Company 26620
- _
INSURER C:
500 County Road 37 East
Maple Lake, MN 55358
INSURER 0:
2,000,000
INSURER _E ; -
INSURER F:
2,000, 000
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR
INDICATED, NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF
THE POLICY
ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT
PERIOD
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED
TO
BY THE POLICIES DESCRIBED HEREIN IS SUBJECT
WHICH THIS
TO ALL
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
THE TERMS,
INSR----_..._ - _._-_____._.-_. _
ADDLSUBR
LTR TYPE OF INSURANCE POLICY NUMBER
_WVD
...- - --- .._ ____.__.
MM DD/YYYY NOoLiC Y YY I LIMITS
X COMMERCIALGENERALLIABILITY
CLAIMS•MADE
EACH OCCURRENCE $
tN
2,000,000
OCCUR
pREMISESOER oc ur ante $
2,000, 000
A
Y
MED EXP (Any one person) $
10,000
GLO 5628661-00
08/31/2022 12/31/20221 PERSONAL & ADV INJURY $
2,000,000
EN'L AGGREGATE LIMIT AP PLIES PER:
--
I
GENERAL AGGREGATE $
,
4,000,000
PRO
I POLICY X JECT LX LOC
-
- --- ---
PRODUCTS - COMP/OP AGG j $
4,000,000
OTHER:Is
AUTOMOBILE LIABILITY
COMBINED SINGLE LIMIT
le
_)(�
LEa accident)_---_--___
5, 000, 000
ANY AUTO
-
BODILY INJURY (Per person)
$
- — -- -----
A
OWNED SCHEDULED I Y BAP 5628663-00
AUTOS ONLY AUTOS !
08/31/2022
12/31/2022
BODILY INJURY (Per accldanU
• $
HIRED NON -OWNED
AUTOS ONLY AUTOS ONLY.
PROPERTY DAMAGE
1
$
-(Per accidenQ_., _ _ .__
$
UMBRELLA LIABX
B OCCUR
EACH OCCURRENCE
$
5,000,000
X {EXCESS LIAB a CLAIMS -MADE P-001-000068228-04
:12/31/2021
12/31/20221
AGGREGATE
$
5,000,000
DED RETENTION$
$
WORKERS COMPENSATION
X PER OTH
AND OS' LIABILITY YINSP
TE"fE ER
L. EACH ACCIDENT I.
-
- - - - -
$ --
5,000,000
A ANYPROPRIETOR/PARTNER/EXECUTIVE
OFFICER/MEMBEREXCLUDED? No N/A', WC 5628662-00 08/31/2022
12/31/20221
(Mandatory In NH)
II yes, describeN under
E.L. DISEASE - EA EMPLOYEE(I
5,000,000
E.L. DISEASE -POLICY LIMIT
—$
$
5,000,000
DESCRIPTIOOF OPERATIONS below I
A ;Workers Compensation/ WC 5628664-00
;08/31/2022
12/31/2022
E.L. Each Accident
$5,000,000
'Employers Liability
IE.L.
Disease -Ea Emp1
$5,000,000
!Per Statute
'IE.L.
Disease -Poi Lmt1$5,000,000
DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space Is required)
SEE ATTACHED
Town of Los Altos Hills
26379 Fremont Road
Los Altos Hills, CA 94022
ACORD 25 (2016/03)
ve�nv`r. r.n
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
W I!dtsti-ZUIb AI;UHU t.;UHF'UHATION, All rights reserved.
The ACORD name and logo are registered marks of ACORD
sR ID: 22970744 BATCH: 2641625
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AGENCY
Willis Towers Watson Midwest, Inc.
POLICY NUMBER
See Page 1
CARRIER
See Page 1
AGENCY CUSTOMER ID:
LOC #:
ADDITIONAL REMARKS SCHEDULE
NAMED INSURED
NP Nexlevel of California, Inc.
500 County Road 37 East
Maple Lake, MN 55358
NAIC CODE
See Page 1 EFFECTIVE DATE: See Page 1
Page 2 Of 2
ADDITIONAL KLMAKr b
THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM,
FORM NUMBER: 25 FORM TITLE: Certificate of Liability Insurance
The Town of Los Altos Hills, its elective and appointed officers, employees, and volunteers are included as Additional
Insureds as respects to General Liability and Auto Liability as required by written contract.
INSURER AFFORDING COVERAGE: Zurich American Insurance Company
POLICY NUMBER: CPP0084169-07 EEE DATE: 05/01/2022 EXP DATE: 05/01/2023
TYPE OF INSURANCE: LIMIT DESCRIPTION: LIMIT AMOUNT:
Leased/Rented Equipment Any One Item/Per Occ $1,000,000
NAIC#: 16535
nnn we-.nnn ••n00nDATIl1hI All rinhtc racArvAd
ACORD 101 (2008!01) �-......... �......_ _
The ACORD name and logo are registered marks of ACORD
SR ID: 22970744 BATCH: 2641625 CERT: W25705572
WILLIS TOWERS WATSON
26 CENTURY BLVD.
6TH FL, SUITE 101
NASHVILLE, TN 37214
4767 1 MB 0.512
'111111111'11'Illl-IIIIIIIIIII III III III 11111111111111111111111111
TOWN OF LOS ALTOS HILLS
26379 W FREMONT RD 4767
LOS ALTOS HILLS, CA 94022-2624
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