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HomeMy WebLinkAboutWorkforce Business Services CAAC..,+t R CERTIFICATE OF LIABILITY INSURANCE [____DATE MM1DDtYYYY) CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, 11/17/2023 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 NAMTACT Todd George Bouchard Insurance for WBS . TG PC Box 6090 PHONE (866) 293 3600 ext. 623 FAC c Ex : AIC No ; Clearwater, FL 33758-6090 ADDRESS: INSURERj8) AFFORDING COVERAGE NAIC # INSURERA; Zurich -American Insurance Company 16535 INSURED Workforce Business Services CA, LLC Labor Contractor, for co -employees of: Mid INSURER B ; INSURER C : EACH OCCURRENCE $ Peninsula Roofing Inc 1401 Manatee Ave. West Ste 600 INSURER D : Bradenton, FL 34205.6706 INSURER INSURER F: _ MED EXP Any one person) $ COVERAGES CERTIFICATE NUMBER' 23FL07AA2n4F,R DO 110rnnl KIIINAo _. __... __,..... ..... ......___.__ ,�,..MIVIV IM IY4i IYIL]L:1�. 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. IL7R TYPE OF INSURANCE Aug 1. POLICY NUMBER POLICY EFF M D/YY Y POLICY BXP MMIDDIYYYY �� LIMITS 00 MERCIAL GENERAL LIABILITY CLAIMS -MADE 0 OCCUR EACH OCCURRENCE $ a ED PREMISES occurrence) $ _ MED EXP Any one person) $ PERSONAL&ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: POLICY F—] IOC _ GENERAL AGGREGATE $ j o� PRODUCTS -COMP/OPAGG $ $ OTHER: AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ Ea accident ANY AUTO INJURY (Per person) $ OWNED SCHEDULEDBODILY - BODILY INJURY (Per accident) $ AUTOS ONLY AUTOS HIRED r NON -OWNED AUTOS ONLY AUTOS ONLY PROPERT DAMAGE per accident $ $ UMBRELLALIAB OCCUR — EACH OCCURRENCE $ EXCESS LIAB CLAIMS -MADE AGGREGATE $ QED RETENTION $ WORKERS COMPENSATION X pR AND EMPLOYERS' LIABILITY Y / N STA UTE E.L. EACH ACCIDENT $ 1,000,000 A ANYPROPRIETOR/PARTNEOF ICER/MEMBEREXC UDED?ECUTIVE ❑ N/A WC 90-00-875-13 12/31/2023 12/31/2024 E.L. DISEASE -EA EMPLOYEE $ 1,000,000 Mandatory in NH) (f Ies, describe under E,L. DISEASE - POLICY LIMIT $ 11000,000 D S ,RIPTION OF OPERATIONS below Location Coverage Period: 12/31/2023 12/31/2024 Client# 053763 DESCRIPTION OF OPERATIONS I LOCATIONS /VEHICLES (ACORD 101, Additional Remarks Schedule, maybe attached if more space is required) Mid Peninsula Roofing Inc Coverage Is provided for only those co -employees 1326 Marsten Road of, but not subcontractors Burlingame, CA 94010 to: GER IlFIGAls HOLDER I ATIMI Town of Los Altos Hills SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE 26379 Fremont Rd Los Altos Hills, CA 94022 THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE ©1988.2015 ACORD CORPORATION. All rights reserved. ACORD 26 (2016/03) The ACORD name and logo are registered marks of ACORD