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COI - Balch Petroleum Contractors & Builders, Inc. - Expires 2024-01-01RAI CPFT-nl KCHANORA ,acoRO CERTIFICATE OF LIABILITY INSURANCE OATE(Z/2022 12Izs/zaz2 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 pollcy(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 endorsements . PRODUCER License # 0757776 co ACT Van Dang HUB International Insurance Services Inc. C P. O. Box 4047 fsS Concord, CA 94524-4047 PHONE FAx uc. Nn. El): 877 825-2681 A C. No : 951 231-2572 E-NfAI . cal.cpu@hubinternational.com INSURERS AFFORDING COVERAGE NAICA INSURER A: State Compensation Insurance Fund of California 35076 INSURED INSURER B: INSURER C: Balch Petroleum Contractors 8. Builders, Inc. INSURER o: P.O. Box 361230 Milpitas, CA 95036 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 TYPE OF INSURANCE Wan ADDLISUBRI wurl POLICY NUMBER POLICY EFF POLICY EXP LIMITS COMMERCIAL GENERAL LIABILITY CLAIMS -MADE ❑ OCCUR EACH OCCURRENCE S DAMAGETORENTED MED EXP (Any onecareer) PERSONAL S ADV INJURY GEN'L AGGREGATE LIMIT APPLIES PER: POLICY jV&- LOC OTHER: GENERAL AGGREGATE PRODUCTS-COMPIOPAGG S S AUTOMOBILE LIABILITY ANY AUTO AIJTOIS ONLY AUUpTTf.IO.pSSWyUyN�ryEEDp AURTOS ONLY AUTO V6NO COMBINED SINGLE LIMIT(EA accidarO $ BODILY INJURY Per parsoul $ BODILY INJURY Per accident S FOPErJRdem SAGE $ UMBRELLA LIAR EXCESS LIAB CLAIMS -MADE EACH OCCURRENCE $ HOCCUR AGGREGATE S DED RETENTION$ S A WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANY PROPRIETORIPARTNER/EXECUTIVE YIN ApN�Y PROMEEMBEEREXCTNERIE �Y (Mandaroryln NH) If yes, describe under DESCRIPTION OF OPERATIONS below NIA X 9039224.2023 1/1/2023 1/l/2024 X PER OTH- E.L EACH ACCIDENT 1,000,000 E.1- DISEASE - EA EMPLOYEE S 1,000,000 E.L. DISEASE - POLICY LIMIT 1,000,000 $ DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, maybe anached if more space is required) RE: Construction of Fuel Station Secondary Containment Components Repair project, 21-PW-264. Waiver of Subrogation with regard to Workers Compensation applies in favor of City of Gilroy when required by written contract per the attached endorsement form SCIF Form 10217.0418. 30-Day Notice of Cancellation with regard to Workers Compensation per attached SCIF Form 10217-0112. CFRTIFICATF HOI nFR CANCFI I ATIr1M L5� SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE City of Gilroy tY Y Public Works Department JAN 2 5 2023 THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Attn: Sara Soto AUTHORIZED REPRESENTATIVE Street GILROY CITY CLERK'S OFFICE 735oy, Gilroy, CA 95020 CA 50 ACORD 25 (2016103) © 1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD ENDORSEMENT AGREEMENT WAIVER OF SUBROGATION BLANKET BASIS HOME OFFICE SAN FRANCISCO ALL EFFECTIVE DATES AT 12:01 AM PACIFIC STANDARD TIMETHE TIME INDICATED ATT January EFFECTIVE J1, 2023 AT 12:01 AM. PACIFIC STANDARD TIME AND EXPIRING January 1, 2024 AT 12:01 AM Balch Petroleum Contractors & Builders, Inc. PO BOX 361230 MILPITAS, CA 95036 Page 1 9039224-23 RENEWAL Greater Bay Area 3069034 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. PERSON OR ORGANIZATION ANY PERSON OR ORGANIZATION FOR WHOM THE NAMED INSURED HAS AGREED BY WRITTEN CONTRACT TO FURNISH THIS WAIVER SCHEDULE JOB DESCRIPTION BLANKET WAIVER OF SUBROGATION NOTHING IN THIS ENDORSEMENT SHALL BE HELD TO VARY, ALTER, WAIVE OR EXTEND ANY OF THE TERMS, CONDITIONS, AGREEMENTS, OR LIMITATIONS OF THIS POLICY OTHER THAN AS ABOVE STATED. NOTHING ELSEWHERE IN THIS POLICY SHALL BE HELD TO VARY, ALTER, WAIVE OR LIMIT THE TERMS, CONDITIONS, AGREEMENTS OR LIMITATIONS IN THIS ENDORSEMENT COUNTERSIGNED AND ISSUED AT SAN FRANCISCO; December 30, 2021 4 AUTHORIZED REPRESENTATIVE 2572 SCIF FORM 10217 (REV.4 -2018) tip.. PRESIDENT AND CEO OLD DP 217 ENDORSEMENT AGREEMENT CERTIFICATE HOLDERS' NOTICE HOME OFFICE SAN FRANCISCO EFFECTIVE JANUARY 1, 2023 AT 12.01 A.M. ALL EFFECTIVE DATES ARE AT 12:01 AM PACIFIC STANDARD TIME OR THE TIME INDICATED AT PACIFIC STANDARD TIME Balch Petroleum Contractors & Builders, Inc. PO BOX 361230 MILPITAS, CA 95036 BROKER COPY REP 06 9039224-23 RENEWAL NB 3-06-90-34 PAGE 1 OF 1 ANYTHING IN THIS POLICY TO THE CONTRARY NOTWITHSTANDING, IT IS AGREED THAT THIS POLICY SHALL NOT BE CANCELLED UNTIL, 30 DAYS AFTER WRITTEN NOTICE OF SUCH CANCELLATION HAS BEEN PLACED IN THE MAIL BY STATE FUND TO CURRENT HOLDERS OF CERTIFICATE OF WORKERS' COMPENSATION INSURANCE. 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: AUTHORIZED REPRESENT IVE SCIF FORM 10217 (REV.1-2012) JANUARY 10, 2013 fw� PRESIDENT AND CEO 2065 OLD DP 217 f:7_TLT73 dli-.7N: VA I1 117:12 T AcollO" CERTIFICATE OF LIABILITY INSURANCE DATE(MMmDmY 1 znsnozz 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(les) 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 endorsements . PRODUCER License # 0757776 Co AcT Van Dang HUB International Insurance Services Inc. P. 0. Box 4047 Concord, CA 945244047 PHONE FAX uc, N0 Exl: (877 825-2681 (AI, N^: 951 231-2572 I . cal.cpu@hubinternational.com INSURERIBI AFFORDING COVERAGE NAICIf INSURER A: State Compensation Insurance Fund of California 35076 INSURED INSURERS: INSURER C: Balch Petroleum Contractors & Builders, Inc. INSURER D : P.O. Box 361230 Milpitas, CA 95036 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 TYPE OF INSURANCE JN=SUn POLICY NUMBER POLICY EFF POLICY EXP LIMBS COMMERCIAL GENERAL LIABILITY CLAIMS -MADE ❑OCCUR EACH OCCURRENCE $ DAMAGE TO RENTED REMMED EXP An one arson $ PERSONAL 8 ADV INJURY GEN'L AGGREGATE LIMIT APPLIES PER: POLICY ❑ j T 0 LOC OTHER: GENERAL AGGREGATE PRODUCTS - COMPIOP AGO S S AUTOMOBILE LIABILITY ANYAUTO OWNED SCHEDULED AUTOS ONLY AUTOS p AUTOS ONLY AUTOS O0 COMBINED SINGLE LIMB S BODILY INJURY Per erson S BODILY INJURY Per accident PPerr amEe^t AMAGE S S UMBRELLA LIAR EXCESS LIAB OCCUR CLAIMS�MADE EACH OCCURRENCE AGGREGATE DED RETENTION$ A WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANY PROPRIEf9OERR/PARTNER/E%ECUTNE YIN I anCatu P NHI EXCLUDED? If as, describe under DESCRIPTION OF OPERATIONS below NIA 9039224-2023 1H/2023 111/2024 X STERTUTZ OTH- E.L. EACH ACCIDENT $ 1,000,000 E.L. DISEASE - EA EMPLOYE 1,000,006 $ E.L. DISEASE - POLICY LIMIT 1,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached If more space Is mqulmd) For Information purposes only. City of Gilroy Building Department 7351 Rosanna St Gilroy, CA 95020-0000 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. JAN 2 5 2023 AUTHORIZEDREPRESENTATNE GILROY MY CLERICS OFFICE — ACUKU 25 (ZUIbIUJ) U 1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD POLICY NUMBER: 0253708-02-276067 EFFECTIVE: 11/09/21 ADDRESS TYPE: ADDITIONAL INSURED CITY OF GILROY, ITS OFFICERS, REPRESENTATIVES, AGENTS AND EMPLOYEES 7351 ROSANNA ST GILROY CA 95020-6141 75-133 YOUR REPRESENTATIVE: CHURCH & CASUALTY INSURANCE AGENCY 3440 IRVINE AVE, SUITE 150 NEWPORT BEACH CA 92660 (800)995-7525 DEC 13 2022 GILROY CITY CLEWS OFFICE PROTECTING Church THE GREATER ,Mutual GOOD INSURANCE IMPORTANT - ATTACH TO YOUR POLICY CHURCH MUTUAL INSURANCE COMPANY, S.I. CHANGE ENDORSEMENT THIS ENDORSEMENT FORMS A PART OF THE POLICY NUMBERED BELOW: ENDORSEMENT EFFECTIVE DATE: 11/09/21 POLICY EFFECTIVE DATE: 11 /09/21 VICTORY OUTREACH GILROY 7401 HANNA ST G I LROY CA 95020-5792 SUMMARY CHANGES TO YOUR POLICY: POLICY NO.: 0253708-02-276067 PLEASE SEE ATTACHED FORM A 2014.1(12-07) ADDITIONAL INSURED - DESIGNATED PERSON OR ORGANIZATION FOR SPECIFIC ACTIVITY - PRIMARY. PREMIUM: NO ADDITIONAL PREMIUM DUE AGENT: 75-133 CHURCH & CASUALTY INSURANCE AGENCY 3440 IRVINE AVE, SUITE 150 NEWPORT BEACH CA 92660 (800) 995-7525 UN 412 (02-20) CHANGE ENDORSEMENT PAGE 1 PROTECTING Church THE GREATER Mutual GOOD' INSURANCE ISSUED DATE: 12/05/22 14 0 w THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. 0 s N ADDITIONAL INSURED DESIGNATED PERSON OR ORGANIZATION 0 FOR SPECIFIC ACTIVITY - PRIMARY 0 w 0 Additional Insured Person(s) or Organization(s): Name: CITY OF GILROY. ITS OFFICERS. REPRESENTATIVES AGENTS AND EMPLOYEES Address: 7351 ROSANNA ST G I LROY CA 95020-6141 City State ZIP Activity: HARVEST FESTIVAL Date(s): 10-31-22 The General Liability Additional Provisions Form is amended to add the following: The Who is An Insured paragraph is amended to include as an insured the person(s) or organization(s) as shown above, but only with respect to "bodily injury," "property damage," personal injury," and "advertising injury" liability arising solely out of the operations of the Named Insured that are directly related to the activity shown above and only for the dates shown above. Subject to paragraph one above, the insurance provided by this endorsement is primary to any applicable insurance issued specifically to the person(s) or organization(s) identified above and no insurance of the person(s) or organization(s) listed above shall be called on to contribute to a loss, notwithstanding any provision to the contrary in the General Liability Coverage Form. 30 The insurance afforded by this endorsement shall not be canceled except after days prior written notice has been given to the insured organization listed above. A 2014.1 (12-07) copyright, Church Mutual Insurance Company. 2007 Page 1 of 1 Includes copyrighted material of ISO Properties, Inc., with its permission. Copyright, ISO Properties, Inc., 2004.