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Total Aquatic Management - Insurance Certificate (2018)REQUEST FOR WAIVER OF WORKERS COMPENSATION INSURANCE If the insured /vendor has no employees, or employees who are subject to the labor code, please sign the following affidavit: I certify that in the performance of the work under the permit, license agreement, purchase order, or contact with the City of Gilroy which is the subject matter of this certification, 1 shall not, in any manner, employ any person or contract with any person so that any worker on said work would become subject to the workers' compensation laws of the State of California. AM 1�3 C, Name (Print) 0 C�C' Pt C tj� Sign ture Date Vendor /Permittee TOTAAQU -01 RRICARDOJR Acofz° CERTIFICATE OF LIABILITY INSURANCE DATE(MM /DD/YYYY) 02/16/2018 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 rights to the certificate holder in lieu of such endorsement(s). PRODUCER Santa Barbara, CA - PRSU - HUB International Insurance Services Inc. 40 E Alamar AVE Santa Barbara, CA 93105 CONTACT Ray Ricardo NAME: PHONE 805 879 -9525 FAX (A/C, No, Ext): ( ) (A/C, No):(805) 617 -1767 E-MAIL ray .ricardojr @hubinternational.com INSURERS AFFORDING COVERAGE NAIC p 04/14/2017 INSURER A: Evanston Insurance Company 35378 $ 1,000,000 INSURED INSURER B:Ohio Security Insurance Company 24082 INSURER C: Underwriters at Lloyd's London 15792 Total Aquatic Management INSURER D : 2250 A Buena Vista Ave Alameda, CA 94501 INSURER E 7 G L AGGREGATE LIMIT APPLIES PER: POLICY❑ JECT PRO F-1 LOC OTHER: INSURER F: $ 2,000,000 PRODUCTS - COMP/OP AGG COVERAGES CERTIFICATE NUMBER: 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. INSR LTR TYPE OF INSURANCE ADDL INSD SUBR WVp POLICY NUMBER POLICY EFF p 1YYYYl POLICY EXP (MMIDDIYYYYI LIMITS A X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE F_X] OCCUR 3EH5438 04/14/2017 0411412018 EACH OCCURRENCE $ 1,000,000 DAMAGE TO RENTED PREMISES (El occurrence 100,000 $ MED EXP (Any one person) $ 5,000 PERSONAL & ADV INJURY $ 1,000,000 7 G L AGGREGATE LIMIT APPLIES PER: POLICY❑ JECT PRO F-1 LOC OTHER: GENERAL AGGREGATE $ 2,000,000 PRODUCTS - COMP/OP AGG $ 1,000,000 $ B AUTOMOBILE LIABILITY ANY AUTO OWNED X SCHEDULED AUTOS ONLY AUTOS X AUTOS ONLY X AUUTOS ONLYY BAS56269387 12/16/2017 12/16/2018 COMBINED SINGLE LIMIT Ea accident 1,000,000 $ BODILY INJURY Per person) $ BODILY INJURY Per accident $ PPeOr acc dent AMAGE Fe $ $ UMBRELLA LIAB EXCESS LIAB OCCUR CLAIMS -MADE EACH OCCURRENCE $ AGGREGATE $ DED I I RETENTION $ 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 PER OTH- STATUTE ER E.L. EACH ACCIDENT $ E.L. DISEASE - EA EMPLOYE $ E.L. DISEASE - POLICY LIMIT $ C Errors & Omissions 7700468 0411012017 04/10/2018 1,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space Is required) Evidence of insurance is provided to the certificate holder listed below. City of Gilroy 7351 Rosanna St 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 ACORD 25 (2016/03) ©1988 -2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD COMMERCIAL GENERAL LIABILITY III POLICY NUMBER: 3EH5438 MARKED EVANSTON INSURANCE COMPANY THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. BLANKET ADDITIONAL INSURED This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE FORM LIQUOR LIABILITY COVERAGE FORM OWNERS AND CONTRACTORS PROTECTIVE LIABILITY COVERAGE FORM PRODUCTS /COMPLETED OPERATIONS LIABILITY COVERAGE FORM SCHEDULE Additional Premium: $ 5oo . oo (Check box if fully earned.❑X ) A. Who Is An Insured is amended to include as an additional insured any person or entity to whom you are obligated by valid written contract to provide such coverage, but only with respect to negligent acts or omissions of the Named Insured and only with respect to any coverage not otherwise excluded in the policy. However: 1. The insurance afforded to such additional insured only applies to the extent permitted by law; and 2. If coverage provided to the additional insured is required by a contract or agreement, the insurance afforded to such additional insured will not be broader than that which you are required by the contract or agreement to provide for such additional insured. Our agreement to accept an additional insured provision in a contract is not an acceptance of any other provisions of the contract or the contract in total. When coverage does.not apply for the Named Insured, no coverage or defense will apply for the additional insured. No coverage applies to the additional insured shown in the Schedule of this endorsement for injury or damage of any type to any "employee" of the Named Insured or to any obligation of the additional insured to indemnify another because of damages arising out of such injury or damage. B. With respect to the insurance afforded to these additional insured, the following is added to limits of insurance: If coverage provided to the additional insured is required by a contract or agreement, the most we will pay on behalf of the additional insured is the amount of insurance: 1. Required by the contract or agreement; 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 remain unchanged. MEGL 0009 -01 05 16 Includes copyrighted material of Insurance Services Office, Inc., Page 1 of 1 with its permission.