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AmeriNational Community Services - Insurance Certificate (2019)AMERCOM -01 MGRIFFANTI ,a►`CORL� CERTIFICATE OF LIABILITY INSURANCE COVERAGES CERTIFICATE NUMPIFR- DP%IICInAI r.0 rnn000. 11 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. DATE Y) TYPE OF INSURANCE 06/01/2018 06/01 /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 License # CA #0658748 AHT Insurance 1460 Broadway Suite 16023 New York, NY 10036 CONTACT NAME: PHONE (A /C, No, Ext): (703) 777 -2341 FAX No):(703) 771 -1852 E -MAIL ADDRESS: X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE X OCCUR X INSURERS AFFORDING COVERAGE NAIC # INSURER A: Great Northern Insurance Company 20303 EACH OCCURRENCE INSURED INSURER B: Federal Insurance Company 20281 INSURER C: Colony Insurance Company 39993 AmeriNational Community Services, LLC dba AmeriNat 217 S. Newton Avenue Albert Lea, MN 56007 INSURER D: INSURER E: INSURER F: PERSONAL & ADV INJURY COVERAGES CERTIFICATE NUMPIFR- DP%IICInAI r.0 rnn000. 11 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 AINSD SWVD POLICY NUMBER POLICY EFF MM /DD/YYYY POLICY EXP MM /DD /YYYY LIMITS A X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE X OCCUR X 36031757 05/29/2018 05/29/2019 EACH OCCURRENCE $ 1,000,000 DAMAGE TO RENTED PREMISES Ea occurrence 1,000,000 $ MED EXP (Any one erson $ 10,000 PERSONAL & ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER POLICY 11 JECT PRO- [X] PRO- GENERAL AGGREGATE $ 2,000,000 PRODUCTS - COMP /OP AGG $ Included OTHER: A AUTOMOBILE LIABILITY Ea aBINEDtSINGLE LIMIT $ 1,000,000 BODILY INJURY Per person) $ ANY AUTO OWNED SCHEDULED AUTOS ONLY AUTOS HIRED X NON -OWNED AUTOS ONLY AUTOS ONLY 73588835 05/29/2018 05/29/2019 BODILY INJURY Per accident $ X PROPERTY DAMAGE Per accident $ B X UMBRELLA LIAB EXCESS LIAB X OCCUR CLAIMS -MADE 79898650 05/29/2018 05/29/2019 EACH OCCURRENCE $ 5,000,000 AGGREGATE $ 5,000,000 DED RETENTION $ $ B WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANY PROPRIETOR /PARTNER /EXECUTIVE YIN �– OFFICER /MEMBER EXCLUDED? (Mandatory in a If yes, describe under �—' DESCRIPTION OF OPERATIONS below N / A 77171555 05/29/2018 05/29/2019 I X PER I OTH- STATUTE ER E.L. EACH ACCIDENT___ 1,000,000 E.L. DISEASE - EA EMPLOYEE E.L. DISEASE - POLICY LIMIT 1,000,000 $ $ 1,000,000 C Management Liability ML 7601398 -03 05129/2018 05/29/2019 See Next Page DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) "'General Liability, Automobile Liability and Umbrella Liability include OSP as a Named Insured`* SEE ATTACHED ACORD 101 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 �4 ;_o AI;VKU Z5 (ZU1b1UJ) © 1988 -2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD ' 1 ACORV " 166� AGENCY CUSTOMER ID: AMERCOM -01 LOC #: 0 ADDITIONAL REMARKS SCHEDULE MGRIFFANTI Page 1 of 1 AGENCY License # CA #0658748 NAMED INSURED HT Insurance AmeriNational Community Services, LLC dba AmeriNat 217 S. Newton Avenue POLICY NUMBER Albert Lea, MN 56007 EE PAGE 1 USA CARRIER NAIC CODE EE PAGE 1 SEE P 1 EFFECTIVE DATE: SEE PAGE 1 AUUI I IUNAL KtIVIAKK5 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 Liabiiity (D &O) Limit: $3,000,000 Retention: $0/$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: ASG18DO01692 Carrier: Underwriters at Lloyd's, London Effective Dates: 05/2912018- 05/29/2019 Limits: $3,000,000 Retention: $10,000 Errors & Omissions Liability: Policy Number: B0507 F1800060 Carrier: Underwriters at Lloyd's, London Effective Dates: 05/2912018- 05/29/2019 Limits: $3,500,000 Retention: $150,000 Mortgage Bond: Policy Number: MBBA -17 -00337 Carrier: Underwriters at Lloyd's, London Effective Dates: 05/29/2018- 05/29/2019 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 (05/07) attached. AI.UKU 9U1 (LUUtf /U1) U 2008 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD CHUBS" Liability Insurance Endorsement Policy Period Effective Date Policy Number Insured i 1aMIG GI `�ii3rnpany Date Issued This Endorsement applies to the following forms: GENERAL LIABILITY MAY 29, 2018 TO MAY 29, 2019 MAY 29, 2018 3603 -17 -57 ECE AMERINATIONAL COMMUNITY SERVICES, LLC DBA AMERINAT GREAT NORTHERN INSURANCE COMPANY MARCH 1, 2018 Under Who Is An Insured, the following provision is added Who Is An Insured Additional Insured - Persons or organizations shown in the Schedule are insureds; but they are insureds only if you are Scheduled Person obligated pursuant to a contract or agreement to provide them with such insurance as is afforded by Or Organization this policy. However, the person or organization is an insured only: • if and then only to the extent the person or organization is described in the Schedule; • to the extent such contract or agreement requires the person or organization to be afforded status as an insured; • for activities that did not occur, in whole or in part, before the execution of the contract or agreement; and • with respect to damages, loss, cost or expense for injury or damage to which this insurance applies. No person or organization is an insured under this provision: • that is more specifically identified under any other provision of the Who Is An Insured section (regardless of any limitation hpplicable thereto). • with respect to any assumption of liability (of another person or organization) by them in a contract or agreement. This limitation does not apply to the liability for damages, loss, cost or expense for injury or damage, to which this insurance applies, that the person or organization would have in the absence of such contract or agreement. Liability Insurance Additional insured - Scheduled Person or nlzation Form B I-02 -2367 (Rev. 5 -07) Endorsement continued Page 1 CHUBBe Liability Endorsement (continued) Under Conditions, the following provision is added to the condition titled Other Insurance, Conditions Other Insurance — If you are obligated, pursuant to a contract or agreement, to provide the person or organization Primary, Noncontributory shown in the Schedule with primary insurance such as is afforded by this policy, Wen in such case Insurance — Scheduled this insurance is primary and we will not seek contribution from insurance available to such person Person Or Organization or organization, Schedule Persons or organizations that you are obligated, pursuant to a contract or agreement, to provide with such insurance as is afforded by this policy. All other terms and conditions remain unchanged. Authorized Representative Liability Insurance Additional insured - scheduled person Or FAFM LAM An - - .. rga8lZatlOn -- V —11 cnoorsement last page Page 2 v, C H U B B° Liability Insurance Endorsement Policy Period MAY 29, 2017 TO MAY 29, 2018 Effective Date MAY 29, 2017 Policy Number 3603 -17 -57 ECE Insured AMERINATIONAL COMMUNITY SERVICES, LLC DAA AMERINAT, Name of Company GREAT NORTHERN INSURANCE COMPANY Date Issued MAY 12, 2017 This Endorsement applies to the following forms: YOUZURME12101WA Under Who Is An Insured, the following provision is added. Who Is An Insured Additional Insured - Persons or organizations shown in the Schedule are insureds; but they are insureds only if you are Scheduled Person obligated pursuant to a contract or agreement to provide them with such insurance as is afforded by Or Organization this policy. However, the person or organization is an insured only: • if and then only to the extent the person or organization is described in the Schedule; • to the extent such contract or agreement requires the person or organization to be afforded status as an insured; • for activities that did not occur, in whole or in part, before the execution of the contract or agreement; and • with respect to damages, loss, cost or expense for injury or damage to which this insurance applies. No person or organization is an insured under this provision: • that is more specifically identified under any other provision of the Who Is An Insured section (regardless of any limitation applicable thereto). • with respect to any assumption of liability (of another person or organization) by them in a contract or agreement. This limitation does not apply to the liability for damages, loss, cost or expense for injury or damage, to which this insurance applies, that the person or organization would have in the absence of such contract or agreement. Liability Insurance Addldonal Insured - Scheduled Parson orOMwIL -atlon continued Form 80.02 -2367 (Rev. 5-07) Endorsement Page 1 CHUBS° Liability Endorsement (continued) Under Conditions, the following provision is added to the condition titled Other Insurance. Conditions Other Insurance — If you are obligated, pursuant to a contract or agreement, to provide the person or organization Primary, Noncontributory shown in the Schedule with primary insurance such as is afforded by this policy, then in such case Insurance — Scheduled this insurance is primary and we will not seek contribution from insurance available to such person Person Or Organization or organization. Schedule - - - CM OF Gn ROY, PPS MOLOYEES, OFFICERS, OFFICIALS AND VOLUNTEERS 7351 ROSANNA STREET Gn ROY, CA 95010 -6141 All other terms and conditions remain unchanged. Authorized Representative Liability Insurance Addiffonal Insured - Schedulad Person or Organization last page Form SO-CL -2987 (Rev. 5.07) Endorsement Pegg 2