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Teichert Construction - Insurance Certificate (2020)Page 1 of 2 '`�'' 0 CERTIFICATE OF LIABILITY INSURANCE DATE(MM/D2019 > I 05/14/019 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 CONTACT NAME: Willis Insurance Services of California, Inc. PHONE 1-877-945-7378 IFAX 1-888-467-2378 c/o 26 Century Blvd (A[C, No. Ext): (A/C. No): E-MAIL certificates@willis.com P.O. Box 305191 ADDRESS: Nashville, TN 372305191 USA INSURERS) AFFORDING COVERAGE NAIC INSURER A:. Liberty Mutual Fire Insurance Company 23035 INSURED INSURER B : Allied World Assurance Company US Inc 19489 A. Teichert & Son, Inc. DBA: Teichert Construction 5200 Franklin Dr., Suite 115 INSURER C : Liberty Insurance Corporation 42404 Pleasanton, CA 94588 USA INSURER D: INSURER E : INSURER F : COVERAGES CERTIFICATE NUMBER: W11229506 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. INSn TYPE OF INSURANCE ADDL StioR LTR INSD WVD POLICY EFF POLII.Y EeAP LIMITS POLICY NUMBER (MM/DD/YYYY) (MM/DD/YYYY) X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 2 , 000 , 000 � DAMAGE TO 1,000,000 CLAIMS -MADE OCCUR PREMISESS((Ea occurrence) $ A X XCU, Contractual Liab & Broad I MED EXP (Any one person) $ 10,000 X Form Prop Damage Included Y EB2-661-067002-039 03/31/2019 03/31/2020 I PERSONAL & ADV INJURY $ 2, 000, 000 GEN'L AGGREGATE LIMIT APPLIES PER: I GENERAL AGGREGATE $ 4,000,000 PRO - X [X] I 4,000,000 POLICY J CT LOC PRODUCTS - COMP/OP AGG $ OTHER: SIR $ 750,000 AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ 2,000,000 (Ea accident) X ANY AUTO I BODILY INJURY (Per person) $ A OWNED SCHEDULED Y EU2-661-067002-049 03/31/2019 03/31/2020 I BODILY INJURY (Per accident) $ _ AUTOS ONLY AUTOS X HIRED X NON -OWNED I PROPERTY DAMAGE $ _ AUTOS ONLY _ AUTOS ONLY (Per accident) SIR $ 500000 B UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 5r000,000 X EXCESS LIAB CLAIMS -MADE 0308-2614 03/31/2019 03/31/2020 I AGGREGATE $ 5, 000, 000 I X I 0 DED RETENTION $ $ I WORKERS COMPENSATION X 13ER ( I OTT AND EMPLOYERS' LIABILITY C ANYPROPRIETOR/PARTNER/EXECUTIVE Y / N UTE I E.L. EACH ACCIDENT $ 1, 000, 000 OFFICER/MEMBEREXCLUDED? ❑ N/A Y EW7-66N-067002-019 03/31/2019 03/31/2020 (Mandatory in NH) I E.L. DISEASE - EA EMPLOYEE $ 1,000,000 If yes, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT $ 1, 000, 000 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) RE: FY19 Citywide Pavement Maintenance Project (Teichert No. 11178.00) Named Insured is a California qualified self -insurer registered under #1867. Workers'. Compensation Policy #EW7-66N-067002-019 provides Excess Workers' Compensation / Employer's Liability coverage excess of a $750,000 SIR. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. City of Gilroy AUTHORIZED REPRESENTATIVE City Engineer 7351 Rosanna Street Gilroy, CA 95020 ©1988-2016 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD SR ID: 17963696 BATCH: 1198092 AGENCY CUSTOMER ID: LOC #: AC<:> ADDITIONAL REMARKS SCHEDULE Page 2 of 2 AGENCY �5200 NAMEDINSURED Willis Insurance Services of California, Inc. A. Teichert & Son, Inc. DBA: Teichert Construction Franklin Dr., Suite 115 POLICY NUMBER Pleasanton, CA 94588 USA See Page 1 CARRIER NAIC CODE I See Page 1 I See Page 1 I EFFECTIVE DATE: See Page 1 ADDITIONAL REMARKS THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, FORM NUMBER:25 FORM TITLE: Certificate of Liability Insurance RE: FY19 Citywide Pavement Maintenance Project (Teichert No. 11178.00). The City of Gilory, its officers, officials, employees, and volunteers are included as Additional Insureds as respects to General Liability and Auto Liability, but solely in regards to work being performed by or on behalf of the Named Insured in connection with the job described herein. It is understood and agreed that this insurance is Primary.and any other insurance maintained by the Additional Insureds shall be excess only and not contributing with this insurance. Waiver of Subrogation applies as respects Excess Workers' Compensation per endorsement attached as permitted by law. ACORD 101 (2008101) © 2008 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD SR ID: 17963696 BATCH: 1198092 CERT: W11229506 Policy.Number: EB2-661-067002-039 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - OWNERS, LESSEES OR CONTRACTORS - SCHEDULED PERSON OR ORGANIZATION This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Name Of Additional Insured Person(s) Location(s) Of Covered Operations Or Organization(s): The City of Gilory, its officers, officials, employees, ALL LOCATIONS AS REQUIRED BY A WRITTEN and volunteers CONTRACT OR AGREEMENT ENTERED INTO PRIOR TO AN "OCCURRENCE" OR OFFENSE Information required to complete this Schedule, if not shown above, will be shown in the Declarations. A. Section II — Who Is An Insured is amended to include as an additional insured the person(s) or - organization(s) shown in the Schedule, but only with respect to liability for "bodily injury", "property damage" or "personal and advertising injury" caused, in whole or in part, by: 1. Your acts or omissions; or 2. The acts or omissions of those acting on your behalf; in the performance of your ongoing operations for the additional insured(s) at the location(s) desig- nated above. B. With respect to the insurance afforded to these additional insureds, the following additional exclu- sions apply: This insurance does not apply to "bodily injury" or "property damage" occurring after: 1. All work, including materials, parts or equip- ment furnished in connection with such work, on the project (other than service, maintenance or repairs) to be performed by or on behalf of the additional insured(s) at the location of the covered operations has been completed; or CG 20 10 07 04 © ISO Properties, Inc., 2004 Page 1 of 2 2. That portion of "your work" out of which the injury or damage arises has been put to its in- tended use by any person or organization other than another contractor or subcontractor en- gaged in performing operations for a principal as a part of the same project. Page 2 of 2 © ISO Properties, Inc., 2004 CG 20 10 07 04 POLICY NUMBER: EB2-661-067002-039 COMMERCIAL GENERAL LIABILITY CG 20 37 07 04 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - OWNERS, LESSEES OR CONTRACTORS - COMPLETED OPERATIONS This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART Name Of Additional Insured Person(s) Or Organ ization(s): The City of Gilory, its officers, officials, employees, and volunteers SCHEDULE Location And Description Of Completed Operations All locations as required by a written contract or agreement entered into prior to an "occurrence" or offense Information required to complete this Schedule, if not shown above, will be shown in the Declarations. Section II — Who Is An Insured is amended to include as an additional insured the person(s) or organization(s) shown in the Schedule, but only with respect to liability for "bodily injury" or "property dam- age" caused, in whole or in part, by "your work" at the location designated and described in the sched- ule of this endorsement performed for that additional insured and included in the "products -completed operations hazard". CG 20 37 07 04 © ISO Properties, Inc., 2004 Page 1 of 1 ❑ Policy Number: EB2-661-067002-039 COMMERCIAL GENERAL LIABILITY CG 20 01 0413 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. PRIMARY AND NONCONTRIBUTORY - OTHER INSURANCE CONDITION This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE PART The following is added to the Other Insurance Condition and supersedes any provision to the contrary: Primary And Noncontributory Insurance This insurance is primary to and will not seek contribution from any other insurance available to an additional insured under your policy provided that: (1) The additional insured is a Named Insured under such other insurance; and (2) You have agreed in writing in a contract or agreement that this insurance would be primary and would not seek contribution from any other insurance available to the additional insured. CG 20 01 0413 © Insurance Services Office, Inc., 2012 Page 1 of 1 Policy Number EU2-661-067002-049 Issued by LIBERTY MUTUAL FIRE INSURANCE COMPANY THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. DESIGNATED INSURED This endorsement modifies insurance provided under the following: EXCESS AUTOMOBILE LIABILITY INDEMNITY POLICY SELF -INSURED TRUCKER EXCESS LIABILITY POLICY With respect to coverage provided by this endorsement, the provisions of the Coverage Form apply unless modified by the endorsement. This endorsement identifies person(s) or -organization(s) who are insureds under the Who Is An Insured Provision of the Coverage Form. This endorsement does not alter coverage provided in the Coverage Form. Each person or organization shown in the Schedule is an insured for Liability Coverage, but only to the extent that person or organization qualifies as an insured under the �,nYho Is An Insured Prr%%Anion contained in Section II of the Coverage Form. Schedule Name of Person(s) or Organization(s): The City of Gilory, its officers, officials, employees, and volunteers AM 76 21 07 13 © 2013 Liberty Mutual Insurance. All rights reserved. Page 1 of 1 /' EXCESS INSURANCE POLICY FOR SELF INSURER OF WORKERS COMPENSATION AND EMPLOYERS LIABILITY WAIVER OF SUBROGATION — RECOVERY FROM OTHERS We have the right to recover any payments which we have made to you from anyone liable for such loss. We will not enforce our right against the person or organization named in the Schedule. This endorsement shall not operate directly or indirectly to benefit anyone not named in the Schedule. Schedule WHERE REQUIRED BY CONTRACT OR A WRITTEN AGREEMENT PRIOR TO LOSS AND ALLOWED BY LAW Issued by Liberty Insurance Corporation For attachment to Policy No.EW7-66N-067002-019 Effective Date 03/31/2019 Premium $ Issued to Teichert, Inc. GPO 4249 Ed. 01/01/1992 Page 1 of 1