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AmeriNat - Insurance CertificateAMERCOM -A1 IYALCH /ACOO2De �_,_� CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DD/YYYY) 05(MMIDDN7 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 ri hts to the,certiflcate holder in lieu of such'eodorsement(s). PRODUCERcLicense 8 CA#0658748 - RRIJACT AHT Insurance One Evertrust Plaza PHONE NC, No, Ela : (703) 777 -2341 A/c No): (703) 7714852. " X Suite 1202 Jersey City, NJ 07302 INSURERS AFFORDING COVERAGE NAIC A INSURER A: Great Northern Insurance Company 20303 INSURED INSURER 8: Federal Insurance Company 20281 INSURER C: Colony Insurance Company 39993 AmeriNational Community Services, LLC dba AmeriNat INSURER D: PERSONAL & ADV INJURY 217 S. Newton Avenue Albert Lea, MN 56007 .INSURER E GENERAL AGGREGATE INSURER.F : PRODUCTS- COMP/OPAGG Included CBVFRArFS CFRTIFIt ATIP NIIMRFR- RI= VIStnM IW INARCR- 4 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 TYPE OF INSURANCE AODL SUER POLICY NUMBER POLICY. EFF POLICY EXP LIMITS A X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE T OCCUR X 36031757 _ 05/29/2017 _ .. 05/29/2018 .... EACH OCCURRENCE $ 1,000,000 DAMAGE TO RENTED ISES (Ea occurrence) $ 1,000,000 MED EXP,(Any one person) $ 10,000 PERSONAL & ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: POLICY j LOC °.._ .. OTHER: GENERAL AGGREGATE 2,000,000 PRODUCTS- COMP/OPAGG Included _.. A AUTOMOBILE' LIABILITY ANY AUTO::'. , _.... _. -.... .. ' OWNED SCHEDULED AUTOOS ONLY" AUUTNOSy "yNEp AUTOS ONLY X AUTO ONLY 73588835. 0512812017 0512912018 COMBINED SINGLE LIMIT (Ea accident) 3 1,000,000 BODILY - INJURY Per: eison _ BODILY IN Per accident $ X (Moor p�dOent AMAGE B X UMBRELLA LIAB EXCESS LIAS �dl IOCCUR CLAIMS -MADE 79898650 05/29/2017 051`2912018 EACH OCCURRENCE 5,000,000 AGGREGATE 5,000,000 DED RETENTION :$ B — ANOD EMPLOYERS' UABIILITNY ANY PROPRIETOR/PARTNER/EXECUTIVE YIN FFICERIM EXCLUDED? �N yes, describe In �i It es, eescribe under . .DESCRIPTION OF OPERATIONS below NIA 77171555 05/28/2017 05/29/2018 X STEARTUTE OTH- E.L. EACH ACCIDENT $ 1,000,000 E.L. DISEASE - EA EMPLOYE 1,000;000 E.L. DISEASE - POLICY LIMIT 1 000,000 . . _' _ __ C' Management Liability ML 760138842 05/29/2017 0512812018 See Next Page - DESCRIPTION OF OPERATIONS / LOCATIONS I VEHICLES (ACORD 101 Additional Remarks Schedule, may be attached H in apace Is required) — General Liability, Automobile Liability and Umbrella Liability Include OSP as a Named Insured— SEE ATTACHED ACORD 101 The ACORD name and logo are registered marks of ACORD SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE CI of Gilroy y 7351 Rosanna St THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Gilroy, CA 85020 - AUTHORIZED REPRESENTATIVE ACORD 25 (2016103) ®1988 -2015 ACORD CORPORATION. All riahts reserved. The ACORD name and logo are registered marks of ACORD ACOREP" AGENCY CUSTOMER ID: AMERCOM -01 LOC a: 1 ADDITIONAL REMARKS SCHEDULE JYALCH Page 1 of 1 AGENCY HT Insurance _ License # CA#0658748 NAMED INSURED AmeriNational Community Services, LLC dba AmeriNat 217 S. Newton Avenue MN 56007 - USA voucY NuMaQi SEE EE PAGE 1 CARRIER NAIC CODE EE PAGE 1 SEE P 1 EFFECTIVE DATE: SEE PAGE 1 ;4a 'l►_A:I:�7 THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, FORM NUMBER: ACORD 25 FORM TITLE: Certificate of Liability insurance Description of Operations/Locations/Vehicles: Management. Liability (D &O/EPLI/FID) Maximum Aggregate Limit: $5,000,000 Directors & Officers Liability (D &O) Limit: $3,000,000. Retention: $01$150,000/$150,000 Employment Practices Liability (EPLI) Limit: $2,000,000 Retention: $75,000 Fiduciary Liability (FID) Limit: $2,000,000 Retention: $50,000 Cyber Liability Policy Number. ASF17DO01692 Carrier: Underwriters at Lloyd's, London Effective Dates: 0512912017 -05/29/2018 Limits: $3,000,000 Retention: $10,000 Errors & Omissions Liability: Policy Number. B0507 N17FT09380 Carrier: Underwriters at Lloyd's, London Effective Dates: 05/29/2017 -05129_/2018 Limits: $3,500,000 Retention: $150,000 Mortgage Bond: Policy Number: MBBA -16 -00205 Carrier. Underwriters at Lloyd's; London Effective Dates: 05/29/2017 -05/29/2018 Limits: $8,500,000 Deductible: $50,000 Certificate Holder, its officers, representatives, agents and employees are included as Additional Insureds under the General Liability as required by written contract per form #80 -02 -2367 (05107) attached. ACORD 101 120081011 © 2008 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD CHUBS° UaNifty Insurance Endorsement PO&7 POW MAY 29, 2017 TO MAY 29, 2018 EJfeciive Date MAY 29, 2017 Aunty Number 3603 -17 -57 ECE Insured OSP, LLC DRA OSRIEN- STANLEY PA,R7NE W Name of G xAmy [TREAT NORIUM DISURANCE COMPANY Bete Issued MARCH 9, 2017 This BOMMMent, applies to the Mowing t GENERAL LdABILM Under Who is An bmnvd, the Wowing providion is added Who to An Insured Add&lbi l Insured - POISON or MlXdzaftm shown m the Schedule are but they ar$ >ceorede only, It you. ere Scheduled Persian oblisaW pm cant to a contract or W== to pravide them with such woe as is aftded by Or Orgenlrslfan us pommy, However, the person or organization is an bssaead only: • if and titan only W this oxtett the person or cWAzadon is in the S lc, • to the I I ' ' I such contractor egraementmqutft the peaaon or oxgani»tonto be dh*d staaos as an banvd; • for activities that did not oaxn, in whole or in part, before the execution of the contractor agroenhent; and • with m dpmasos, las% cost or eapense For injury or damage to which this insaramx No pawn or mVmIWW is an ho wed under this p v4 d= • that is mace specifically identified under any other provision of the Who ra An bsured =don (retpudiessofany litwia app&ablethereto). ' with respect to any assumption of liabiHiy (of anotherperaoa or mgW1=11on)by them in a contractor agrnemaht. This iimiaton does not apply to the liability for damages, lass, cost or es x=for injury or damage, to which this inaunince gTliM that tho pesaou or ag miratan would have in the absence of auch contractor agrmient. LW ft bmurmme AdAMWk=W &ftdWsdPer W01OpgW on ROW 002367 (Rev. "7) Enda�aement -- t CHU' E3ET L(abMfy Endorsomsnt (oontinusd) Undw Otiadidaus.dw followingpmvidw is added to the cto dem titledOtbw Ium=c e. commons Other ftwxhnce — If you are obligated, pubot to acontractor ag=mout,to provide the pa= or won Prhrwyl shown In dte Sdodule wfdt primary i wmm each sa is affm&d by this policy, dm lu such ear Insurance — Scheablsd this im mum is pslrnary and•we will not seek canufbntton ftm imsmance avaflableto such person Person Or Qrgwkgfran or orgamzatfon. Persons or orgsaiz was that you we obligated, pm um to a c omut or agroe=t, to pmvW v ftb mssch inmsace as is afi<arded by d*Vliey. All othat teYmB and conditioas main nnchaag 4 Atrt W&SdRepr9aerltatMa bra was A*UNWlMasd- W"dedit agOr09W&RUM iwpw rte. CH U B Be Liability Insurance Endorsement Pb&y Period EICwft Dote Pb&yNumber Msured MAY 29, 2017 TO MAY 29, 2019 MAY 29, 2017 3603 -17 -37 Eta± AMERWATIONAL COhDAUMff SERVICES, LLC DAA AMERINAT. Neme of Company GREAT NORTHM INSURANCE CDWANY Date Issued MAY 12.2017 This Eudorsemnt applies to the following forms: GENERAL UAW= Under Who Is An Insured, rho following provision is added. Who Is An knuned AddlBonW Insured - Persons or orgenizadons shown in the Schedule are homnode; but they aria humveds only if you ere ScdteMed Penon obligated parent to a con= or agreement to provide them with such insurance as is Warded by Or p on this policy. However, the person or orgaaizedon is an hmnvd only. • if and thew only to the eatmt dw person or organization is described in the Sdwdule; • to the eaM such contract m agreement rem the person or otganizffion to be afforded statas as anhMM4. • for activities that did not occur, in whole or in part, before the eaecudon of the contract or agreement a • with nespecttp damages. Ions, cost or expanse for injury or damage to which this inea:a m applies. No person or organization is an im wW under this provisiao: • thatis more specifically idendfled under any odwprovldon of the Who Is An Iosuted section ftardless of any limitation applicable thereto). • with respect to any asenmpdon of liability (of another person or ) by them in a contract or egteemmt. This limitation does not apply to the liability for dmn mss, im cost or expense for injary or darmga, to which this Insurance applies, that ihe person or n would hame in the absence of each contractor agreement. LhWft twurenm AMtlorrsl h%xn d - Sd"WP8MW OrQV nt 0W COO SAW Faun 8o Q2MW(Rev. 847) Endaraer W9 - -- - PO M h ) to m a� tl..l �s m C g� S g i pO� A 9