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AmeriNational Community Services - Insurance Certificate (2020)AMERCOM-01 MGRIFFANTI CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) 5/29/2019 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 CONTACT AHT Insurance PHONE 1460 Broadway (A/C, No, Ext): (703) 777-2341 FAx Suite 16023 I E-MAIL (A/C, No):(703) 771-1852 ADDRESS: New York, NY 10036 INSURER(S) AFFORDING COVERAGE NAIC # INSURED AmeriNational Community Services, LLC dba AmeriNat 217 S. Newton Avenue Albert Lea, MN 56007 wsURERA:Great Northern Insurance Company_ 20303 INSURER B: Federal Insurance Company 20281 INSURER C : Peleus Insurance Company 34118 INSURER D : INSURER E : INSURER F : COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: 1 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 SAID CLAIMS. INSR ADDL SUBR POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER (MM/DDnrYYY) (MM/DD/YYYY) LIMITS A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE Is 1,000,000 CLAIMS -MADE X X PREMISESS(Ea occurrence) OCCUR 36031757 5/29/2019 5/29/2020 DAMAGERENTED 1,000,000 ($ MED EXP (Any one person) $ 10,000 PERSONAL & ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 POLICY JERK ® LOC PRODUCTS - COMP/OP AGG $ Included) OTHER: $ 1 A AUTOMOBILE LIABILITY CO BINEDtSINGLE LIMIT $ (EaANY 1,000,0001 AUTO 73588835 5/29/2019 5/29/2020 BODILY INJURY (Per I $ J OWNED SCHEDULED AUTOS ONLY AUTOS _ person) BODILY INJURY (Per accident) $ 1 X HIRED X NON -OWNED AUTOS ONLY PROPERTY DAMAGE AUTOS ONLY (Per accident) $ B X UMBRELLA LIAB X OCCUR $ EACH OCCURRENCE I $ 1 5,000,0001 EXCESS LIAB CLAIMS -MADE 79898650 5/29/2019 5/29/2020 AGGREGATE $ 5,000,0001 DED RETENTION $ $ B WORKERS COMPENSATION X IPER I I AND EMPLOYERS' LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE Y 77171555 5/29/2019 STATUTE �RH 5/29/2020 $ E.L. EACH ACCIDENT 1,000,000 OFFICER/MEMBERIGER/MEMBER EXCLUDED? N /A (Mandatory in NH) E.L. DISEASE - EA EMPLOYEEI $ 1,000,000 If yes, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT I $ 1,000,000 C Management Liability ?PIL7601398-4 612912019 5/29/2020 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 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 7351 Rosanna St ACCORDANCE WITH THE POLICY PROVISIONS. Gilroy, CA 95020 AUTHORIZED REPRESENTATIVE ACORD 25 (2016/03) ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD AGENCY CUSTOMER ID: AMERCOM-01 MGRIFFANTI LOC #: 0 ACORV" ADDITIONAL REMARKS SCHEDULE Page 1 of 1 �. AGENCY License # CA#0658748 NAMED INSURED AHT Insurance AmeriNational Community Services, LLC dba AmeriNat 217 S. Newton Avenue POLICY NUMBER Albert Lea, MN 56007 SEE PAGE 1 CARRIER NAIC CODE SEE PAGE 1 SEE P 1 EFFECTIVE DATE. SEE PAGE 1 ADDITIONAL REMARKS THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, FORM NUMBER: ACORD 25 FORM TITLE: Certificate of Liability Insurance Description of Operations/LocationsNehicles: Management Liability (D&O/EPLI/FID) Maximum Aggregate Limit: $5,000,000 Directors & Officers Liability (D&O) Limit: $3,000,000 Retention: $0/$150,000/$150,000 Employment Practices Liability (EPLI) Limit: $2,000,000 Retention: $100,000 Fiduciary Liability (FID) Limit: $2,000,000 Retention: $50,000 Cyber Liability Policy Number: ASH19DO01692 Carrier: Underwriters at Lloyd's, London Effective Dates: 05/29/2019-05/29/2020 Limits: $3,000,000 Retention: $10,000 Errors & Omissions Liability: Policy Number: B0507 F11900853 Carrier: Underwriters at Lloyd's, London Effective Dates: 05129/2019-05/29/2020 Limits: $4,000,0000 Retention: $150,000 Mortgage Bond: Policy Number: MBBA-18-00337 Carrier: Underwriters at Lloyd's, London Effective Dates: 05/2912019-05/2912020 Limits: $13,500,000 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 (05107) attached. ACORD 101 (2008101) © 2008 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD C W U a all Liability insurance Endorsement Policy Period Effective Date Policy Number Insured Name of Company Date Issued This Endorsement applies to the following forms: GENERAL LIABILITY Who Is An Insured MAY 29, 2019 TO MAY 29, 2020 MAY 29, 2019 3603-17-57 ECE AMERINATIONAL COMMUNITY SERVICES, LLC DBA AMERINAT GREAT NORTHERN INSURANCE COMPANY FEBRUARY 28, 2019 Under Who Is An Insured, the following provision is added. Additional Insured - Persons or organizations shown in the Schedule are insureds; but they are lawreds 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 inured 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 Additional Insured - Scheduled Person Or Organization continued Form 80-02-2367 (Rev. 5-07) Endorsement Page 1 c H u a s" Liability Endorsement (continued) Conditions Other Insurance - Primary, Noncontributory Insurance -- Scheduled Person Or Organization Under Conditions, the following provision is added to the condition titled Other Insurance. If you are obligated, pursuant to a contract or agreement, to provide the person or organization shown in the Schedule with primary insurance such as is afforded by this policy, then in such case this insurance is primary and we will not seek contribution from insurance available to such person 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 ' na Liability Insurance Additional Insured - Scheduled Person Or Organization last page Form 80.02-2867 (Rev. 5-07) Endorsement Page 2 C H U B B° Liability Insurance Endorsement Policy Period MAY 29, 2017 TO MAY 29, 2018 Effective Dale MAY 29, 2017 Policy Number 3603-17-57 ECE Insured AMMINATIONAL COMMUNITY SERVICES, LLC DAA AN ERINAT. Name of Company GREAT NORTHERN INSURANCE COMPANY Date Issued MAY 12, 2017 This Endorsement applies to the following forms: GENERAL LIABUM 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 Addfdonal Insured - Scheduled Parson or organLmvcn conUnued Form 80,02-2367 `Rov. 5-07) Endcrraement Page f 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. CITY OF GILROY, ITS EMPLOYEES, 0M-, CERS, O C ]AI S. AND VOLUNTEERS 7351 ROSANNA a ir.=L GILROY, CA 95020-6141 All other teams and conditions remain unchanged. Authorized Representative Liability Insurance AddVornal Insured - Scheduled Person Or OrganInNon last page Form &),Q 2367 (Rev. 5-07) Endorsement Page 2 AMERCOM-01 MGRIFFANTI CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) 5/29/2019 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 CONTACT NAME: _ AHT Insurance PHONE 703 777-2341 FAX 70 1460 Broadway (A/C, No, Ext): ( ) (A/C, No):( 3) 771-1852 Suite 16023 E-MAIL ADDRESS: New York, NY 10036 INSURER(S) AFFORDING COVERAGE NAIC # INSURER A: INSURED INSURER B : AmeriNational Community Services, LLC dba AmeriNat INSURER C : 217 S. Newton Avenue INSURER D : Albert Lea, MN 56007 INSURER E INSURER F : 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 ADDL SUBR POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER (MM/DD/YYYY) (MM/DD/YYYY) LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ CLAIMS -MADE F OCCUR DAMAGE TO RENTED PREMISES (Ea occurrence) $ MED EXP (Any one person) $ PERSONAL & ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: I GENERAL AGGREGATE $ PRO - POLICY LOC JECT PRODUCTS -COMP/OP AGG $ OTHER: $ AUTOMOBILE LIABILITY A COMBINED SINGLE LIMIT (Ea accident) $ ANY AUTO BODILY INJURY (Per person) $ OWNED SCHEDULED AUTOS ONLY AUTOS BODILY INJURY (Per accident) $ HIRED NON -OWNED PROPERTY DAMAGE AUTOS ONLY AUTOS ONLY (Per accident) $ UMBRELLA LIAB OCCUR HCLAIMS-MADE EACH OCCURRENCE $ EXCESS LIAB AGGREGATE $ DED RETENTION $ $ WORKERS COMPENSATION PER OTH- I I AND EMPLOYERS' LIABILITY Y / N STATUTE ER ANY PROPRIETOR/PARTNER/EXECUTIVE E.L. EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? N / A ❑ (Mandatory in NH) E.L. DISEASE - EA EMPLOYEE $ If yes, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT $ 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 CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE City of Gilroy THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Y y ACCORDANCE WITH THE POLICY PROVISIONS. its Employees, Officers, Officials and Volunteers 7351 Rosanna Street Gilroy, CA 95020-6141 AUTHORIZED REPRESENTATIVE I 4:� �W ACORD 25 (2016/03) ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD AGENCY CUSTOMER ID: AMERCOM-01 MGRIFFANTI LOC #: 0 ACGORL7" ADDITIONAL REMARKS SCHEDULE Page 1 of 1 AGENCY License # CA#0658748 NAMED INSURED AHT Insurance AmeriNational Community Services, LLC dba AmeriNat 217 S. Newton Avenue POLICY NUMBER Albert Lea, MN 56007 SEE PAGE 1 CARRIER NAIC CODE SEE PAGE 1 SEE P 1 EFFECTIVE DATE: SEE PAGE 1 ADDITIONAL REMARKS 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 Liability (D&O) Limit: $3,000,000 Retention: $0/$150,000/$150,000 Employment Practices Liability (EPLI) Limit: $2,000,000 Retention: $100,000 Fiduciary Liability (FID) Limit: $2,000,000 Retention: $50,000 Cyber Liability Policy Number: ASH19DO01692 Carrier: Underwriters at Lloyd's, London Effective Dates: 05129/2019-05/29/2020 Limits: $3,000,000 Retention: $10,000 Errors & Omissions Liability: Policy Number: B0507 F11900853 Carrier: Underwriters at Lloyd's, London Effective Dates: 05/29/2019-05/2912020 Limits: $4,000,0000 Retention: $150,000 Mortgage Bond: Policy Number: MBBA-18-00337 Carrier: Underwriters at Lloyd's, London Effective Dates: 05/2912019-05/29/2020 Limits: $13,500,000 Deductible: $50,000 ACORD 101 (2008/01) © 2008 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD C H U a a° Liability Insurance Endorsement Policy Period Effective Date Policy Number Insured Name of Company Date Issued This Endorsement applies to the following forms: GENERAL LIABILITY Who Is An Insured MAY 29, 2019 TO MAY 29, 2020 MAY 29, 2019 3603-17-57 ECE AMERINATIONAL COMMUNITY SERVICES, LLC DBA AMERINAT GREAT NORTHERN INSURANCE COMPANY FEBRUARY 28, 2019 Under Who Is An Insured, the following provision is added 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 Additional insured - Scheduled Person Or Organization continued Form 80-02-2367 (Rev. 5-07) Endorsement Page i USS" 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 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 Organization last page Form 80-02 2367 (Rev. 5-07) Endorsement Page 2