Personal Impressions - Insurance Certificate (2019)® CERTIFICATE OF LIABILITY INSURANCE DATE (MM
07/17/2018
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
-PRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER.
.1ORTANT: 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 CONTACT Erin Alexander
NAME:
RISI, dba Pan American Insurance Services a/c NN Ext: (831)233 -7383 (Ac No): (877)693 -9831
201 Monterey Salinas Hwy E -MAIL erin .aexander @relationinsurance.com
ADDRESS:
Suite G INSURER(S) AFFORDING COVERAGE NAIC #
Salinas CA 93908 INSURER A: Security National 19879
INSURED INSURER B:
Personal Impressions INSURER C :
331 El Cerrito Way INSURER D:
INSURER E:
Gilroy CA 95020 INSURER F:
COVERAGES CERTIFICATE NUMBER: 2018 Master RFVISInN NII IIURPP-
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 CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
CERTIFICATE MAYBE 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
AUVL
INSD
SU13K
WVD
POLICY NUMBER
POLICY EFF
(MMIDD/YYYY)
POLICY EXP
(MM /DD/YYYY)
LIMITS
COMMERCIAL GENERAL LIABILITY
EACH OCCURRENCE
$ 1,000,000
CLAIMS -MADE rX OCCUR
DAMA E I U RENTED
PREMISES Ea occurrence)
$ 50,000
MED EXP (Any one person)
$ 5,000- -
PERSONAL & ADV INJURY
$ 1,000,000
A
Y
NA105295006
04127/2018
04/27/2019
GEN'L AGGREGATE LIMIT APPLIES PER:
GENERAL AGGREGATE
$ 2,000,000
PRO-
POLICY PRO
JECT LOC
PRODUCTS - COMP /OPAGG
1,000,000
$
$
OTHER:
AUTOMOBILE
LIABILITY
COMBINED SINGLE LIMIT
(Ea accident
$
BODILY INJURY (Per person)
$
ANYAUTO
OWNED SCHEDULED
AUTOS ONLY AUTOS
BODILY INJURY (Per accident)
$
HIRED NON -OWNED
AUTOS ONLY AUTOS ONLY
PROPERTY DAMAGE
(Per accident)
$
UMBRELLA LIAB
HCLAIMS-MADE
OCCUR
EACH OCCURRENCE
$
AGGREGATE
$
EXCESS LIAR
DED I I RETENTION $
$
WORKERS COMPENSATION
PER 70TH
AND EMPLOYERS' LIABILITY Y / N
STA TUTE
ER
E.L. EACH ACCIDENT
$
ANY PROPRIETOR/PARTNER/EXECUTIVE
OFFICER/MEMBER EXCLUDED? El
NIA
E.L. DISEASE - EA EMPLOYEE
$
(Mandatory in NH)
If yes, describe under
E.L. DISEASE - POLICY LIMIT
$
DESCRIPTION OF OPERATIONS below
DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required)
RE: All California Operations
The City of Gilroy, its officers and employees are additional insured
CERTIFICATE HOLDER
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 -2015 ACORD CORPORATION. All rights reserved.
ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD
PHIS ENDORSEMENT CHANGES THE POLIO. PLEASE READ IT CAREFULLY
OWNS S, LESSEES OR CONTRACTORS
This endorsement modifies insurance provided under the following:
COMMERCIAL GENERAL LIABILITY COVERAGE PART
SCHEDULE
Policy Number: NA105295066
Endorsement Effective: 04/27/18 12:01 a.m.
Named Insured
Authorized Representative:
TIMOTHY KEVIN COLLINS
PERSONAL IMPRESSIONS
I
i I
- W
SCHEDULE
Name of Person or
Any person or organization that the named insured is obligated by virtue of a written contract
or agreement to provide insurance such as is afforded by this
Location:
(If no entry appears above, infdrmation required to complete this endorsement will be shown in the Declarations as
applicable to this endorsement.)
A. Section II — Who It An Insured is amended to include as an insured the person or organization
shown in the Schedule, but only to the extent that the person or organization shown in the
Schedule is held lia�le for your acts or omissions arising out of your ongoing operations performed
for that insured. i
S. With respect to the nsurance afforded to these additional insureds, the following exclusion is
added:
2. Exclusions
This insurance oes not apply to "bodily injury" or "property damage" occurring after:
(1) All work, cluding materials, parts or equipment furnished in connection with such work,
on the pr ject (other than service, maintenance or repairs) to be performed by or on
behalf of the additional insured(s) at the site of the covered operations has been
complete; or
(2) That portipn of "your work" out of which the injury or damage arises has been put to its
intended use by any person or organization other than another contractor or
subcontractor engaged in performing operations for a principal as a part of the same
project.
C. The words "you" ano "your" refer to the Named Insured shown in the Declarations.
D. "Your work" means Wont or operations performed by you or on your behalf, and materials, parts or
equipment fumishe in connection with such work or operations.
Primary Wording
If required by written contract or agreement: Such insurance as is afforded by this policy shall be
primary Insurance, and any insurance or self - insurance maintained byithe above additional
insured(s) shall be excess of the insurance afforded to the named insured and shall not contribute
to it.
If required by written . contract or agreement: We waive any right of recovery we may have
against an entity that is an additional insured per the terms of this endorsement because of
payments we make for injury or damage arising out of "your work° done under a contract with
that person or organifation.
49 -0108 0711 May Include Copyrighted Material of Insurance Services Offices, Inc. Page 1 of 1
Used with permission
POLICYHOLDER COPY
NA
P.O. BOX 8192, PLEASANTON, CA 94588
CERTIFICATE OF WORKERS' COMPENSATION INSURANCE
ISSUE DATE: 11 -10 -2017
CITY OF GILROY NA
7301 HANNA ST
GILROY CA 95020-6129
GROUP:
POLICY NUMBER: 9085403 -2017
CERTIFICATE ID: 9
CERTIFICATE EXPIRES: 11 -01 -2018
11 -01- 2017/11 -01 -2018
This is to certify that we have issued a valid Workers' Compensation insurance policy in a form approved by the
California Insurance Commissioner to the employer named below for the policy period indicated.
This policy is not subject to cancellation by the Fund except upon 10 days advance written notice to the employer.
We will also give you 10 days advance notice should this policy be cancelled prior to its normal expiration.
This certificate of insurance is not an insurance policy and does not amend, extend or alter the coverage afforded
by the policy listed herein. Notwithstanding any requirement, term or condition of any contract or other document
with respect to which this certificate of insurance may be issued or to which it may pertain, the insurance
afforded by the policy described herein is subject to all the terms, exclusions, and conditions, of such policy.
Authorized Representative President and CEO
UNLESS INDICATED OTHERWISE BY ENDORSEMENT, COVERAGE UNDER THIS POLICY EXCLUDES THE FOLLOWING:
THOSE NAMED IN THE POLICY DECLARATIONS AS AN INDIVIDUAL EMPLOYER OR A HUSBAND AND WIFE EMPLOYER;
EMPLOYEES COVERED ON A COMPREHENSIVE PERSONAL LIABILITY INSURANCE POLICY ALSO AFFORDING
CALIFORNIA WORKERS' COMPENSATION BENEFITS; EMPLOYEES EXCLUDED UNDER CALIFORNIA WORKERS'
COMPENSATION LAW.
EMPLOYER'S LIABILITY LIMIT INCLUDING DEFENSE COSTS: $1,000,000 PER OCCURRENCE.
EMPLOYER
.OLLINS, TIMOTHY K AND COLLINS, ELIZABETH D
331 EL CERRITO WAY
GILROY CA 95020
[P1V,NA]
REV.7-2014) PRINTED : 11-10-2017
IDS Property Casualty Insurance Company
3500 Packerland Drive t
De Pere, WI 54115 -9070
Elizabeth D Collins
Timothy Collins
331 El Cerrito Way
Gilroy, CA 95020 -4432
RENEWAL DECLARATION
CALIFORNIA
POLICY NUMBER: AI01360117
POLICY PERIOD: 0710512018 - 0110512019
12:01 AM Standard Time
LAPSE IN COVERAGE: NONE
FOR CLAIMS SERVICE CALL:
1- 888 - 404 -5365
FOR CLIENT SERVICE CALL:
1 -888- 404 -5365
COVERAGEILIMIT 1 2007 ACUR 3 2005 CHEV :7 2008 TYTA
NIDX AWD SLVR HD 250 TUNDRA DOUB
BODILY INJURY LIABILITY
$67.00
$69.00
$250,000 EACH PERSON
$500,000 EACH ACCIDENT
'
PROPERTY DAMAGE LIABILITY
INCL
INCL
$100,000 EACH ACCIDENT
MEDICAL EXPENSE - EXCESS COVERAGE
INCL
INCL
$5,000 EACH PERSON
UNINSURED MOTORIST BODILY INJURY
$7.00
$7.00
$25,000 EACH PERSON
$50,000 EACH ACCIDENT
UNINSURED MOTORIST PROPERTY DAMAGE
INCL
$1.00
CAR I- WAIVER OF COLLISION DEDUCTIBLE
CAR 3- WAIVER OF COLLISION DEDUCTIBLE
CAR 7- WAIVER OF COLLISION DEDUCTIBLE
COLLISION
$87.00
$48.00
DEDUCTIBLES CAR 1 -$250 3 -$500 7 -$500
COMPREHENSIVE
$24.00
$6.00
DEDUCTIBLES CAR 1 -$250 3 -$500 7 -$500
TOWING AND LABOR COSTS
$5.00
$5.00
$75 PER DISABLEMENT
RENTAL EXPENSE
NONELECT
NONELECT
CONSOLIDATED VEHICLE ASSESSMENT FEE $0.87 $0.87
TOTAL SEMIANNUAL PREMIUM PER VEHICLE $190.87
CONVENIENCE FEE* - $5.00
TOTAL SEMIANNUAL PREMIUM ALL VEHICLES - $559.61
$136.87
$84.00
INCL
INCL
$8.00
$1.00
$100.00
$28.00
$5.00
NONELECT
$0.87
$226.87
Coverage is provided only when both a premium and limit are shown.
Convenience Fee is $4 per monthly installment if payment is made by credit/debit card or $1 per monthly installment for a preauthorized withdrawal method.
adca0la (001)
0512312018
f DRIVER INFORMATION
I. Elizabeth D Collins 4.
2. Timothy Collins 5.
3. 6.
* QUALIFIES FOR GOOD STUDENT DISCOUNT
+ QUALIFIES FOR MATURE DRIVER DISCOUNT
# EXCLUDED DRIVER
CAR INFORMATION CARS KEPT AT LOCATION OTHER THAN RESIDENCE
2007 ACUR 2HNYD28487H502233
2005 CHEV IGBHC29U65E228014
2008 TYTA 5TBBV58168S522959
YOUR POLICY HAS THE FOLLOWING DISCOUNTS:
MULTI -CAR, PREMIER SAFETY, TENURE, MULTI PRODUCT, COSTCO
2007 ACUR - DUAL AIRBAG, GOOD DRIVER
2005 CHEV - DUAL AIRBAG, GOOD DRIVER
2008 TYTA - DUAL AIRBAG, GOOD DRIVER, ANTI -THEFT DEVICE
YOUR POLICY HAS THE FOLLOWING ENDORSEMENTS:
SPECIAL EQUIPMENT /CUSTOMIZATION: NONE
LIENHOLDER INFORMATION
2005 CHEV SLVR HD 2500 2WD - Hitachi Capital America Corp Minneapolis, MN
h
cdec09 - CA
CERTHOLDER COPY
NA
P.O. BOX 8192, PLEASANTON, CA 94588
CERTIFICATE OF WORKERS' COMPENSATION INSURANCE
ISSUE DATE: 11-01-2018
CITY OF GILRY NA
7301 HANNA ST
GILROY CA 95020-6129
GROUP:
POLICY NUMBER: 9085403-2018
CERTIFICATE ID: 11
CERTIFICATE EXPIRES: 1 1-01-2019
11-01-2018/11-01-2019
This is to certify that we have issued a valid Workers' Compensation insurance policy in a form approved by the
California Insurance Commissioner to the employer named below for the policy period indicated.
This policy is not subject to cancellation by the Fund except upon 10 days advance written notice to the employer.
We will also give you 10 days advance notice should this policy be cancelled prior to its normal expiration.
This certificate of insurance is not an insurance policy and does not amend, extend or alter the coverage afforded
by the policy listed herein. Notwithstanding any requirement, term or condition of any contract or other document
with respect to which this certificate of insurance may be issued or to which it may pertain, the insurance
afforded by the policy described herein is subject to all the terms, exclusions, and conditions, of such policy.
le�e �114�01
.�7
Authorized Representative President and CEO
UNLESS INDICATED OTHERWISE BY ENDORSEMENT, COVERAGE UNDER THIS POLICY EXCLUDES THE FOLLOWING:
THOSE NAMED IN THE POLICY DECLARATIONS AS AN INDIVIDUAL EMPLOYER OR A HUSBAND AND WIFE EMPLOYER;
EMPLOYEES COVERED ON A COMPREHENSIVE PERSONAL LIABILITY INSURANCE POLICY ALSO AFFORDING
CALIFORNIA WORKERS' COMPENSATION BENEFITS; EMPLOYEES EXCLUDED UNDER CALIFORNIA WORKERS'
COMPENSATION LAW.
EMPLOYER'S LIABILITY LIMIT INCLUDING DEFENSE COSTS: $1,000,000 PER OCCURRENCE.
EMPLOYER
COLLINS, TIMOTHY K DBA: PERSONAL IMPRESSIONS
331 EL CERRITO WAY
GILROY CA 95020
M0408
(REV.7-2014) PRINTED : 10-17-2018