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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