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Complete Paperless Solutions - Insurance Certificate (2019) DATE (MM/DD/YYYY) CERTIFICATE OF LIABILITY INSURANCE 7/11/2018 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 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). CONTACT Van Dang PRODUCER NAME: FAX PHONE (714)619-4493 Robert Harris Insurance Agency, Inc. (714)619-4481 (A/C, No): (A/C, No, Ext): E-MAIL van@reharris.com Lic. #0216736 ADDRESS: 3150 Bristol St., Suite 200 INSURER(S) AFFORDING COVERAGE NAIC # Costa Mesa CA 92626 Travelers Cas Ins Co of America 19046 INSURER A : INSURED Hartford Accident & Indemnity 22357 INSURER B : Complete Paperless Solutions LLC Lloyds of London/S&C INSURER C : 4025 E. La Palma Ave #204 INSURER D : INSURER E : Anaheim CA 92807 INSURER F : 18/19 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. ADDL SUBR INSR POLICY EFF POLICY EXP TYPE OF INSURANCE LIMITS POLICY NUMBER (MM/DD/YYYY) (MM/DD/YYYY) LTR INSD WVD X COMMERCIAL GENERAL LIABILITY 2,000,000 EACH OCCURRENCE $ DAMAGE TO RENTED 300,000 A X CLAIMS-MADE OCCUR $ PREMISES (Ea occurrence) 5,000 6808B847614 6/23/2018 6/23/2019 MED EXP (Any one person) $ 2,000,000 PERSONAL & ADV INJURY $ 4,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ PRO- X 4,000,000 POLICY LOC PRODUCTS - COMP/OP AGG $ JECT $ OTHER: COMBINED SINGLE LIMIT AUTOMOBILE LIABILITY 1,000,000 $ (Ea accident) BODILY INJURY (Per person) $ ANY AUTO A ALL OWNED SCHEDULED BODILY INJURY (Per accident) $ 6808B847614 6/23/2018 6/23/2019 AUTOS AUTOS NON-OWNED PROPERTY DAMAGE X X $ HIRED AUTOS (Per accident) AUTOS $ UMBRELLA LIAB EACH OCCURRENCE $ OCCUR EXCESS LIAB CLAIMS-MADE AGGREGATE $ $ DED RETENTION $ PER OTH- WORKERS COMPENSATION x STATUTE ER AND EMPLOYERS' LIABILITY Y / N 1,000,000 ANY PROPRIETOR/PARTNER/EXECUTIVE E.L. EACH ACCIDENT $ N / A OFFICER/MEMBER EXCLUDED? B 6/23/2018 72WECZX9262 6/23/2019 (Mandatory in NH) 1,000,000 E.L. DISEASE - EA EMPLOYEE $ If yes, describe under 1,000,000 E.L. DISEASE - POLICY LIMIT $ DESCRIPTION OF OPERATIONS below C Errors & Omissions $1,000,000 ESG04471007 1/11/2018 6/23/2019 Each Claim $2,000,000 Ded: $10,000 each claim Aggregate Limit DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) The City of Gilroy, its officers and employees are named Additio as respects operations of the Named Insured (see blanket policy All Members/owners are excluded from Workers Compensation covera Policies are subiect to 10-days Notice of Cancellation in the ev CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN City of Gilroy ACCORDANCE WITH THE POLICY PROVISIONS. 7351 Rosanna Street Gilroy, CA 95020 AUTHORIZED REPRESENTATIVE Steve Harris/VAND © 1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25 (2014/01) The ACORD name and logo are registered marks of ACORD INS025 (201401) WHOISAN II) s ina forthis to to any tion(called youhave ina a toany to to but for youhave only toliability outof forthat to With tothe to outofthe of thefailureto any for Limitsof he limitsof liabilityapply: The failingto Thelimits you toprovide; maps, or- is overanyvalid Polic Number: Endorsement Number: y 72WECZX9262 Effective Date: 06/23/18Effective hour is the same as stated on the Information Pa g e of the p olic y . Named Insured and Address: COMPLETE PAPERLESS SOLUTIONS LLC 4025 E LA PALMA AVE STE 201 A NAHEIMCA92807 Wehavetherighttorecoverourpaymentsfromanyoneliableforaninjurycoveredbythispolicy.Wewillnotenforceour rightagainstthepersonororganizationnamedintheSchedule.(Thisagreementappliesonlytotheextentthatyou perform work under a written contract that requires you to obtain this agreement from us.) Youmustmaintainpayrollrecordsaccuratelysegregatingtheremunerationofyouremployeeswhileengagedinthework described in the Schedule. Theadditionalpremiumforthisendorsementshallbe2%oftheCaliforniaworkers'compensationpremiumotherwisedue on such remuneration. SCHEDULE Person or OrganizationJob Description Any person or organization from whom you are required by written contract or agreement to obtain this waiver of rights from us Countersigned by Authorized Representative Form WC 04 03 06 (1) Printed in U.S.A. Process Date: Policy Expiration Date: 05/14/18 06/23/19