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Alpha Analytical - Insurance Certificate (2020)ALPHANA-01 DFRANSEN Ac'oR0 CERTIFICATE OF LIABILITY INSURANCE DATE9/3/2 D/YYYY) �-� /312019 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 Danielle Fransen NAME: Team Insurance & Financial Services, Inc. PHONE 462-5901 FAX 7 PO Box 1472 (A/C, No, Ext): (707 ) (A/C, No):( 07) 462-3763 Ukiah, CA 95482 ADDRESS: danielle@teamins.net INSURED Alpha Analytical Laboratories, Inc. 208 Mason St. Ukiah, CA 95482 I INSURER(S) AFFORDING COVERAGE NAIC # INSURER A: Arch Specialty Insurance INSURER B: Nationwide Mutual Insurance Companv INSURER C : Employers Comp Ins Co INSURER D INSURER E INSURER F : 21199 11512 I 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 'OLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCE ADDL SUBR POLICY EFF ' POLICY EXP LSR INSD WVD POLICY NUMBER (MM/DD/YYYYI IMMIDD/YYYY) LIMITS e X COMMERCIAL GENERAL LIABILITY 3 000 000 CLAIMS -MADE [X] OCCUR X X 12EMP7204107 GEN'L AGGREGATE LIMIT APPLIES PER: POLICY �X JEC LOC OTHER: B AUTOMOBILE LIABILITY X ANY AUTO ACPBA7800172096 OWNED SCHEDULED AUTOS ONLY AUTOS HIRED NON -OWNED AUTOS ONLY AUTOS ONLY A UMBRELLA LIAR X OCCUR X EXCESS LIAB CLAIMS -MADE 12EMX2225200 DED I I RETENTION $ C WORKERS COMPENSATION AND EMPLOYERS' LIABILITY YIN ANY PROPRIETOR/PARTNER/EXECUTIVE X EIG261089201 OFFICER/MEMBER EXCLUDED? N / A (Mandatory in NH) If yes, describe under pPSC,RIPjION C)E (�P�RATIONS below A Professional la 12EMP7204107 A Pollution Liability 12EMP7204107 "DIP1171i~ 'IDiKOYZt7 EACH OCCURRENCE DAMAGE TO RENTED PREMISES (Ea occurrence) MED EXP (Any one oerson) PERSONAL & ADV INJURY GENERAL AGGREGATE PRODUCTS - COMP/OPAGG $ r I $ 100,0001 $ 5,0001 $ 3,000,0001 $ 3,000,0001 Q 3,000,0001 COMBINED SINGLE LIMIT 1,000,000 11/1/2018 11/1/2019 (Ea accident) BODILY INJURY (Per person) $ $ I BODILY INJURY (Per accident) $ I PROPERTY DAMAGE (Per accident) $ $ EACH OCCURRENCE $ 2,000,0001 6/24/2019 4/6/2020 I 2,000,0001 AGGREGATE $ $ I X STATUTE OERH I 5/1/2019 5/1/2020 1,000,0001 E.L. EACH ACCIDENT $ E.L. DISEASE - EA EMPLOYEE $ 1,000,0001 1,000,0001 E.L. DISEASE - POLICY LIMIT $ 4/612019 4/6/2020 Ea.Occ./Aggregate 3,000,000 41612019 416/2020 Ea.Occ./Aggregate 3,000,000 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space Is required) RE: City of Gilroy Pretreatment Wastewater Processing City of Gilroy, its officers, representatives, agents and employees are named as an Additional Insured on the general liability. Waiver of Subrogation applies. *30 Notice of Cancellation* 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. 7351 Rosanna Street Gilroy, CA 95020 AUTHORIZED REPRESENTATIVE I ACORD 25 (2016103) ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED/ PRIMARY COVERAGE INCLUDING COMPLETED OPERATIONS (COVERAGES A, B, D & F) This endorsement modifies insurance provided under the Environmental Muitiline Policy It is agreed that Section III - WHO IS AN INSURED is amended to include the following: Under Coverages A,B,D and F the person or organization shown in the schedule below shall be an Additional Insured, but only to the extent liability arises out of YOUR WORK for that Additional Insured and not due to any actual or alleged independent liability of said Additional Insured. This Endorsement does not apply to BODILY INJURY or PROPERTY DAMAGE arising out of the sole negligence or willful conduct of, or for defects in design furnished by the Additional Insured. With respect to the coverage afforded to the Additional Insured, this insurance is primary and non- contributory, and our obligations are not affected by any other insurance carried by such Additional Insured whether primary, excess, contingent or on any other basis. This Endorsement does not increase the Company's limits of liability as specified in the Declarations of this policy. Additional Insured: ANY PERSON OR ORGANIZATION FOR WHOM YOU PERFORM WORK UNDER A WRITTEN CONTRACT THAT REQUIRES YOU TO OBTAIN THIS AGREEMENT FROM US. THE WRITTEN CONTRACT MUST BE EFFECTIVE PRIOR TO THE DATE OF THE LOSS OCCURRENCE. All other terms and conditions of this Policy remain unchanged. Endorsement Number:13 Policy Number: 12 EMP 7204107 Named Insured: ALPHA ANALYTICAL LABORATORIES, INC. This endorsement is effective on the inception date of this Policy unless otherwise stated herein: Endorsement Effective Date: 4/6/2019 00 EMP0101 00 01 14 1 of 1 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. WAIVER OF SUBROGATION- SPECIFIC PERSON OR ORGANIZATION ENDORSEMENT This endorsement modifies insurance provided under the Environmental Multilane Policy In consideration of the premium charged, it is hereby agreed that SECTION V, Conditions, paragraph 13. Subrogation is amended to include the following: We agree to waive this right of subrogation against the person or organization shown in the Schedule below to the extent that you had, prior to an OCCURRENCE or CLAIM, a written agreement to waive such rights. Schedule Name of Person or Organization: ANY PERSON OR ORGANIZATION FOR WHOM YOU PERFORM WORK UNDER A WRITTEN CONTRACT THAT REQUIRES YOU TO OBTAIN THIS AGREEMENT FROM US, THE WRITTEN CONTRACT MUST BE EFFECTIVE PRIOR TO THE DATE OF THE LOSS OCCURRENCE. All other terms and conditions of this Policy remain unchanged Endorsement Number:12 Policy Number: 12 EMP 72041 07 Named Insured: ALPHA ANALYTICAL LABORATORIES, INC. This endorsement is effective on the inception date of this Policy unless otherwise stated herein: Endorsement Effective Date: 4/6/2019 00 EMP0052 00 05 04 1 of 1 WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 04 03 06 (Ed. 4-84) WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT-CALIFORNIA We have the right to recover our payments from anyone liable for an injury covered by this policy. We will not enforce our right against the person or organization named in the Schedule. (This agreement applies only to the extent that you perform work under a written contract that requires you to obtain this agreement from us.) You must maintain payroll records accurately segregating the remuneration of your employees while engaged in the work described in the Schedule. The additional premium for this endorsement shall be 2 % of the California workers' compensation premium otherwise due on such remuneration. Schedule Person or Organization Job Description With respect to all employees subject to the workers' compensation laws of the state of California, any person or organization for whom the Named Insured has agreed by written contract to furnish this waiver. This policy is subject to a minimum charge of $250 for the issuance of waivers of subrogation This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated. (The information below is required only when this endorsement is issued subsequent to preparation of the policy.) This endorsement, effective 05/01/2019 at 12:01 AM standard time, forms a part of Policy No. EIG 2610892 01 Of the EMPLOYERS PREFERRED INS. CO. Carrier Code 00920 Issued to ALPHA ANALYTICAL LABORATORIES, Endorsement No. Premium Countersigned at on By: !� Authorized Representative WC 04 03 06 (Ed. 4-84) © 1998 by the Workers' Compensation Insurance Rating Bureau of California. All rights reserved.