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Teen Force - Insurance CertificateTEENF -1 OP ID: LD '4 SRO CERTIFICATE OF LIABILITY INSURANCE 1 DATE M04/27/2015 Y) M / 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 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 NAME: Sheldon Beitzel,CLCS,CWCA,CRIS Suhr Risk Services PHONE 408 - 510 -5440 FAX No 5300 Stevens Creek Blvd. Arc No, Ext): San Jose, CA 95129 E -MAIL Sheldon Beitzel - Selective ADDRESS: INSURERS AFFORDING COVERAGE NAIC # INSURER A: Nonprofits Ins. Alliance of CA INSURED Teen Force INSURERB:State Compensation Ins. Fund 135076 344 Bean Avenue INSURERC:The Hartford 29424 Los Gatos, CA 95030 INSURER D :The Travelers Companies, Inc 125682 INSURER E: INSURER F: C(IVFRAr:PS CERTIFICATE NI IMRFR REVISION NUMRFR- 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. I R LT R LT TYPE OF INSURANCE ADDL UB R POLICY NUMBER Y MM/ D /YYYY MM /DDYYY /Y LIMITS A GENERAL LIABILITY X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE a OCCUR X 201529283 03/01/2015 03/01/2016 EACH OCCURRENCE $ 1,000,00 DAMAG ( RENTED PREMISES S Ea occurrence ) $ 500,00 MED EXP (Any one person) $ 20,00 PERSONAL & ADV INJURY $ 1,000,00 GENERAL AGGREGATE $ 2,000,00 GENT AGGREGATE LIMIT APPLIES PER: POLICY n PRO 7 LOC EC� PRODUCTS - COMP /OP AGG $ 2,000,00 $ A AUTOMOBILE LIABILITY ANY AUTO ALL OWNED SCHEDULED AUTOS AUTOS X HIRED AUTOS X NON -OWNED AUTOS 201529283 03/0112015 03/0112016 COMBINED SINGLE LIMIT Ea accident 1,000,000 $ BODILY INJURY (Per person) __ $ BODILY INJURY (Per accident) $ PER ERTY DAMAGE $ $ A UMBRELLA LAB EXCESS LAB OCCUR CLAIMS -MADE 201529283UMB 03101/2015 03/01/2016 EACH OCCURRENCE $ 1,000,00 AGGREGATE $ 1,000,00 DED I X I RETENTION $ 10,000 $ B WORKERS COMPENSATION EMPLOYERS' LIABILITY ANY PROPRIETOR /PARTNER /EXECUTIVE Y OFFICER /MEMBER EXCLUDED? (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below N/A 188744515 05/01/2015 05101/2016 j X WC STATU- 9TH TORY LIMIT ER E.L. EACH ACCIDENT $ 1,000,00 E.L. DISEASE - EA EMPLOYEE $ 1,000,00 E.L. DISEASE - POLICY LIMIT _ $ 1,000,00 I DESCRIPTION OF OPERATIONS / LOCATIONS ! VEHICLES (Attach ACORD 101, Additional Remarks Schedule, If more space is required) City of Gilroy, it's officers, agents and employees are being included as additional insured per the attached CG2026 endorsement form. Loll ItII;A I t NULI L:ANL;tLLA I IUN City of Gilroy 7351 Rosanna Street Gilroy, CA 95020 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 ©1988 -2010 ACORD CORPORATION. All rights reserved. ACORD 25 (2010105) The ACORD name and logo are registered marks of ACORD