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COI - Live Oak Adult Day Services - Expires 2023-09-10OP ID: TT2 ACOIF? O �._--- CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DD/YYYY) 09/14/2022 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 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 San Jose Insurance Agency Inc. Atlantic -Pacific Ins. Brokers 2542 S. Bascom Ave #280 Campbell, CA 95008 Jose Insurance Agency CONT• NAME: Tina Tremani X340 PHONE 408 371-3700 I FAX (AIC. No Ext): { No): E-MAIL ADDRESS: tina@sanjoseins.com PROSan CUSTOMER ID #: LIVEO-5 NAIC # INSURER(S) AFFORDING COVERAGE INSURED Live Oak Adult Day Services, I 1147 Minnesota Ave San Jose, CA 95125 INSURER A : Nonprofit Ins Alliance of Ca 11384 INSURER a :State Compensation Insurance 35076 INSURER C : INSURER D : INSURER E : INSURER F : COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS INDICATED. CERTIFICATE EXCLUSIONS INSR LTRINSR IS TO CERTIFY THAT THE POLICIES OF INSURANCE NOTWITHSTANDING ANY REQUIREMENT, MAY BE ISSUED OR MAY PERTAIN, AND CONDITIONS OF SUCH POLICIES. SUBR MD LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. TYPE OF INSURANCE ADDL POLICY NUMBER POLICY EFF (MMIDD/YYYY) POLICY EXP (MMIDDIYYYY) LIMITS A GENERAL LIABILITY COMMERCIAL GENERAL LIABILITY OCCUR X 202201332NP0 202201332NP0 09/10/2022 09/10/2022 09/10/2023 09/10/2023 EACH OCCURRENCE $ 1,000,000 X _ DAME TO RENTED PREMISES (a occurrence $ 500,000 CLAIMS -MADE X MED EXP (Any one person) $ 20,000 X Social Services PERSONAL&ADVINJURY $ 1,000,000 Professional GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP/OP AGG $ 2,000,000 3,000,000 X PRO- POLICY 1 PRO I LOC JECT j Agg Profe $ A AUTOMOBILE LIABILITY ANY AUTO ALL OWNED AUTOS SCHEDULED AUTOS HIRED AUTOS NON -OWNED AUTOS NO OWNED VEHICLES 202201332NP0 202201332NP0 09/10/2022 09/10/2022 09/10/2023 09/10/2023 COMBINED SINGLE LIMIT (Ea accident) $ 1,000,000 BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ PROPERTY DAMAGE (PER ACCIDENT) $ X X $ $ UMBRELLA LIAB EXCESS LIAB OCCUR CLAIMS -MADE EACH OCCURRENCE _ $ AGGREGATE $ DEDUCTIBLE RETENTION $ $ $ B WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? (Mandatory In NH) - If yes, describe under DESCRIPTION OF OPERATIONS Y / N N / A X 930114-22 07/01/2022 07/01/2023 X WC STATU- OTH- TORY LIMITS ER EEACH ACCIDENT .L. $ 1,000,000 E.L. DISEASE - EA EMPLOYEE $ 1,000,000 below E.L. DISEASE - POLICY LIMIT $ 1,000,000 A A Directors & Office Improper Sexual Ab 202201332NP0 202201332NP0 09/10/2022 09/10/2022 09/10/2023 09/10/2023 DOLI Limit 1,000,000 1,000,000 DESCRIPTION OF OPERATIONS / LOCATIONS I VEHICLES (Attach ACORD 101, Additional Remarks Schedule if more space is required) Adult day care and related services. City of Gilroy, its Officers, Representatives, Agents & Employees are named as additional insured. Waiver of subrogation applies to workers compensaiton in favor of The City of Gilroy as required by written contract 10Days Notice for non-payment of premium CERTIFICATE HOLDER City of Gilroy, H.C.D. 7351 Rosanna St Gilroy, CA 95020 RE ©CROWEEM SEP 2 0 2022 GILROY CITY CLERK'S OFFICE 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. AUTHORIZED REPRESENTATIVE © 1988-2009 ACORD CORPORATION. All rights reserved. ACORD 25 (2009/09) The ACORD name and logo are registered marks of ACORD POLICY NUMBER: 2022-01332 COMMERCIAL GENERAL LIABILITY Named Insured: Live Oak Adult Day Services, Inc. THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - DESIGNATED PERSON OR ORGANIZATION This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE CG20261219 Name Of Additional Insured Person(s) Or Organization(s): City of Gilroy its Officers,Representatives, Agents and Employees Adult Day Care 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 your acts or omissions or the acts or omissions of those acting on your behalf: 1. In the performance of your ongoing operations; or 2. In connection with your premises owned by or rented to you. However: 1. The insurance afforded to such additional insured only applies to the extent permitted by law; and 2. If coverage provided to the additional insured is required by a contract or agreement, the insurance afforded to such additional insured will not be broader than that which you are required by the contract or agreement to provide for such additional insured. B. With respect to the insurance afforded to these additional insureds, the following is added to Section III — Limits Of Insurance: If coverage provided to the additional insured is required by a contract or agreement, the most we will pay on behalf of the additional insured is the amount of insurance: 1. Required by the contract or agreement; or 2. Available under the applicable Limits of Insurance shown in the Declarations; whichever is less. This endorsement shall not increase the applicable Limits of Insurance shown in the Declarations. CG 20 26 12 19 © Insurance Services Office, Inc., 2012 Page 1 of 1 STATE COMPENSATION INSURANCE FUND ENDORSEMENT AGREEMENT WAIVER OF SUBROGATION BLANKET BASIS HOME OFFICE SAN FRANCISCO EFFECTIVE JULY 1, 2022 AT 12.01 A.M. ALL EFFECTIVE DATES ARE AND EXPIRING JULY 1, 2023 AT 12.01 AT 12:01 AM PACIFIC STANDARD TIME OR THE TIME INDICATED AT PACIFIC STANDARD TIME LIVE OAK ADULT DAY SERVICES 1147 MINESSOTA AVE SAN JOSE, CA 95125 BROKER COPY A.M. 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. THE ADDITIONAL PREMIUM FOR THIS ENDORSEMENT SHALL BE 2.00% OF THE TOTAL POLICY PREMIUM. SCHEDULE PERSON OR ORGANIZATION ANY PERSON OR ORGANIZATION FOR WHOM THE NAMED INSURED HAS AGREED BY WRITTEN CONTRACT TO FURNISH THIS WAIVER JOB DESCRIPTION BLANKET WAIVER OF SUBROGATION 9301142-22 RENEWAL NA 3-34-02-76 PAGE 1 OF 1 NOTHING IN THIS ENDORSEMENT CONTAINED SHALL BE HELD TO VARY, ALTER, WAIVE OR EXTEND ANY OF THE TERMS, CONDITIONS, AGREEMENTS, OR LIMITATIONS OF THIS POLICY OTHER THAN AS STATED. NOTHING ELSEWHERE IN THIS POLICY SHALL BE HELD TO VARY, ALTER, WAIVE OR LIMIT THE TERMS, CONDITIONS, AGREEMENTS OR LIMITATIONS OF THIS ENDORSEMENT. COUNTERSIGNED AND ISSUED AT SAN FRANCISCO: 2572 JULY 5, 2022 • AUTHORIZED REPRESENTAfiIVE PRESIDENT AND CEO SCIF FORM 10217 IREV.7-2014) OLD DP 217