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Home My WebLink AboutCertificate of Insurance (2)ACC7RLIP CERTIFICATE OF LIABILITY INSURANCE d.� DATE(MMIDDIYYYY) 1 10/25/2017 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 poltcy(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 Arthur J. Gallagher & Co. Insurance Brokers of California, Inc. I LIC #0726293 3697 Mt. Diablo Blvd,, Suite 300 CONTACT NAME: Certificate Department PHONE g25-299-1112 FAx 925-953-6270 E-MAIL CertRequests@ajg.com INSURERS AFFORDING COVERAGE NAIC # Lafayette CA 94549 INSURERA:Zurich American Insurance Company 16535 EACH OCCURRENCE $1,000,000 INSURED CHRICOM-02 INSURER B: Chrisp Company 43650 Osgood Road Fremont, CA 94539 INSURER C INSURER D: GENERAL AGGREGATE $2,000,000 PRODUCTS - COMP/OP AGG $2,000,000 INSURER E: INSURER F: AUTOMOBILE LIABILITY X ANY AUTO AAUTOS ONLY ED SCHEDULED AUTOS X AUTOS ONLY X AUTOS ONLY COVERAGES CERTIFICATE NUMBER: 1311094783 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. ILTR TYPE OF INSURANCE ADDLSUBR INSD WVD POLICY NUMBER IDYL MM% MM/ DYE LIMITS A X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE FX OCCUR X BI/PD: $10.000 Y GLO 0217730-01 12/1/2016 12/1/2017 EACH OCCURRENCE $1,000,000 DAMAGE TO RENTED PREMISES Ea occurrence $50,000 MED EXP (Any one person) $5,000 X DED/OCC PERSONAL &ADV INJURY $1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: POLICY E JECT LOC OTHER: GENERAL AGGREGATE $2,000,000 PRODUCTS - COMP/OP AGG $2,000,000 $ AUTOMOBILE LIABILITY X ANY AUTO AAUTOS ONLY ED SCHEDULED AUTOS X AUTOS ONLY X AUTOS ONLY BAP 0217729-01 12/1/2016 12/1/2017 (Ea accidennt E $1,000,000 BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ PROPERTY DAMAGE $ Per accident UMBRELLA LIAB EXCESS LIAB OCCUR CLAIMS -MADE EACH OCCURRENCE $ AGGREGATE $ DED RETENTION $ $ A WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y / N ANY PROPRIETOR/PARTNER/EXECUTIVE ❑ OFFICER/MEMBER EXCLUDED? (Mandatory In NH) If yes, describe under DESCRIPTION OF OPERATIONS below N/A WC 0217731-01 12/1/2016 12/1/2017 X STATUTE EERH E.L. EACH ACCIDENT $1,000,000 E.L. DISEASE - EA EMPLOYEE $1,000,000 E.L. DISEASE - POLICY LIMIT $1,000,000 [SEE ATTACHED SUPPL. PAGE] DESCRIPTION OF OPERATIONS I LOCATIONS /VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached If more space Is required) Chrisp Job #: 1 L.7064. RE: Repaint Curbs Project, Los Altos Hills, CA. ADDITIONAL INSURED(S): The Town of Los Altos Hills, it's elective and appointed officers, employees, and volunteers. GtK 111'IL A I t NULUtK t;ANL;LLLA I ION 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 1J613-ZU15 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD AGENCY CUSTOMER ID: LOC #: n Page of AGENCY I NAMED INSURED POLICY NUMBER CARRIER NAIC CODE EFFECTIVE DATE: TI -IIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, I FORM NUMBER: FORM TITLE: Additional Information GENERAL LIABILITY: "Additional Insured if required by written contract per attached FormU—GL-1175—F CW (04/13) 'Coverage is Primary/Non-Contributory if required by written contract per attacnea U—GL-1175—F CW (04/13) WORKERS' COMPENSATION: * Covered States: California, Nevada, Oregon ACORD 101 (2008101) a0 2008 ACORD CORPORATION_ All rinhtc rwcwrvarl The ACORD name and logo are registered marks of ACORD Additional Insured —Automatic — Owners, Lessees Or Contractors Policy No, EfE Date of Pol. Exp. Date of Pal. Eff. Date of End, Producer No. Add'I. Prem Return Prem. GLO 0217730-01 12/01/2016 12/01/2017 12/01/2016 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE BEAD IT CAREFULLY. Named Insured: Address (including ZIP Code): This endorsement modifies insurance provided under the: Commercial General Liability Coverage Part A. Section 11— Who Is An Insured is amended to include as an additional insured any person or organization whom you are required to add as an additional insured on this policy under a written contract or written agreement. Such person or organization is an additional insured 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 or "your work" as included in the "products -completed operations hazard", which is the subject of the written contract or written agreement. However, the insurance afforded to such additional insured: 1. Only applies to the extent permitted by law; and 2. Will not be broader than that which you are required by the written contract or written agreement to provide for such additional insured. B. With respect to the insurance afforded to these additional insureds, the following additional exclusion applies: This insurance does not apply to: "Bodily injury", "property damage" or "personal and advertising injury" arising out of the rendering of, or failure to render, any professional architectural, engineering or surveying services including: a. The preparing, approving or failing to prepare or approve maps, shop drawings, opinions, reports, surveys, field orders, change orders or drawings and specifications; or b. Supervisory, inspection, architectural or engineering activities, This exclusion applies even if the claims against any insured allege negligence or other wrongdoing in the supervision, hiring, employment, training or monitoring of others by that insured, if the 'occurrence" which caused the "bodily injury" or "property damage", or the offense which caused the "personal and advertising injury", involved the rendering of or the failure to render any professional architectural, engineering or surveying services. U -GL -1175-F CW (04/13) Page 1 of 2 Includes copyrighted material of Insurance Services Office, Inc., with its permission. C. The following is added to Paragraph 2. Duties In The Event Of Occurrence, Offense, Claim Or Suit of Section IV — Commercial General Liability Conditions: The additional insured must see to it that: 1. We are notified as soon as practicable of an 'occurrence" or offense that may result in a claim; 2. We receive written notice of a claim or "suit" as soon as practicable; and 3. A request for defense and indemnity of the claim or "suit" will promptly be brought against any policy issued by another insurer under which the additional insured may be an insured in any capacity. This provision does not apply to insurance on which the additional insured is a Named Insured if the written contract or written agreement requires that this coverage be primary and non-contributory. D. For the purposes of the coverage provided by this endorsement: 1. The following Is added to the Other Insurance Condition of Section IV Commercial General Liability Conditions: Primary and Noncontributory insurance This Insurance is primary to and will not seek contribution from any other Insurance available to an additional insured provided that: a. The additional insured is a Named Insured under such other insurance; and b. You are required by written contract or written agreement that this insurance be primary and not seek contribution from any other insurance available to the additional insured. 2. The following paragraph is added to Paragraph 4.b. of the Other Insurance Condition of Section IV — Commercial General Liability Conditions: This insurance is excess over: Any of the other insurance, whether primary, excess, contingent or on any other basis, available to an additional insured, in which the additional insured on our policy is also covered as an additional insured on another policy providing coverage for the same "occurrence", offense, claim or "suit This provision does not apply to any policy in which the additional insured is a Named Insured on such other policy and where our policy is required by a written contract or written agreement to provide coverage to the additional insured on a primary and non- contributory basis. E. This endorsement does not apply to an additional insured which has been added to this policy by an endorsement showing the additional insured in a Schedule of additional insureds, and which endorsement applies specifically to that identified additional insured. F. With respect to the insurance afforded to the additional insureds under this endorsement, the following is added to Section III — Limits Of Insurance: The most we will pay on behalf of the additional insured is the amount of insurance: 1. Required by the written contract or written agreement referenced in Paragraph A. of this endorsement; 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. All other terms and conditions of this policy remain unchanged. U -GL -1175-F CW (04/13) Page 2 of 2 Includes copyrighted material of Insurance Services Office, Inc., with its permission. To: CONTRACTOR From: Town of Los Altos Hills Re: Agreement Transmittal Memo Enclosed, please find the following documents: AGREEMENT — If you require a fully executed, signed original of the Agreement for your records, please photocopy the Agreement prior to signing the enclosed document. Return both originals with your signature to the Town and a fully executed Agreement will be returned. IRS FORM We9 — Request for Taxpayer Identification Number (TIN) and Certification. This farm is required for all vendors of the Town and it is important that you provide the Town with the correct TIN. If your company is a: Sole Proprietorship - The taxpayer identification number must be the social security number of the sole proprietor. • Partnerships or. Corporations — The taxpayer identification number must be the employer identification number issued to the partnership or corporation. Once all documents have been completed, please return the signed Agreement(s) and IRS Form W-9 to the following address: Town of Los Altos Hills Contracts 26379 Fremont Road Los Altos Hills, CA 94022