COI - Balch Petroleum Contractor and Builders, Inc - Expires 2022-10-15BALCPET-01 RARMAS
'4 o� CERTIFICATE OF LIABILITY INSURANCE DATE 101111l2021021Yj
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 # OE02096 CONTACT
DiBuduo & DeFendis Insurance Brokers, LLC PHONE FAX
P.O. Box 6479 (ac, No, Ext): (559) 432-0222 1(A(c, Hot(559) 431-7941
Fresno, CA 93755-5479 ADDRIE�43:
INSURE S AFFORDING COVERAGE NAIC 0
INSURER A: Oregon Mutual _ 14907
INSURED INSURER B.
Balch Petroleum Contractor and Builders, Inc INSURER C :
PO Box 361230 INSURER D :
Milpitas, CA 95036
INSURER E :
INSURER F :
COVERAGES CRRTIRICATR NI 111Al2=12• bBVICIA\I \II I\afl Cb.
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.
ILT R
TYPE OF INSURANCE ADDL'SUBRI
POLICY NUMBER I POLICY EFF CY FJCP POLI
M
I LIMITS
COMMERCIAL GENERAL LIABILITY
CLAIMS -MADE OCCUR
EACH OCCURRENCE $
DDRA AGE TO RENTED ��}— PISEMED$
MED EXP (Any one person] $
PERSONAL & ADV INJURY $
AGGREGATE LIMIT APPLIES PER:
POLICY FI jECT l_7 LOC I
OTHER:
! GENERAL AGGREGATE
$
GEN'L
PRODUCTS - COMPIOP AGG
�— — ��
A AUTOMOBILE
LIABILITY
MBINED SINGLE LIMIT I 1,000,000
�(CEoa_accidW) $
BODILY INJURY (Per person)
$
X
ANY AUTO X
OWNED SCHEDULED
AUTOS ONLY X AUTOSW Ep
AiJTOS ONLY X AUTO ONNLY
CMO 2
X 9 1839
10/15/2021
10/15/2022
BODILY INJURY (Par accid_ anf
$
PeacEcitlent AMAGE
$
UMBRELLA LIAB I OCCUR
j~
EACH OCCURRENCE i $
EXCESS LIAB CLAIMS -MADE
DED I RETENTION $1� I
j
AGGREGATE $
$
WORKERS COMPENSATION
AND EMPLOYERS' LIABILITYY 1 N
ANY PROPRIETOR/PARTNERIEXECUTIVE
(MaadatR J JE, ft EXCLUDED? N 1 A
if yes, describe under
DESCRIPTION OF OPERATIONS below
I PER OTH-
STATUSE I ER
E.L. EACH ACCIDENT $
E.L. DISEASE - EA EMPLOYEE! $
E.L. DISEASE - POLICY LIMIT
DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, maybe attached if more space Is required)
Project: Fuel Station Secondary Containment Components Repair, Project no. 21-PW— 264
City of Gilroy, its officers, officials, employees, and volunteers are to be covered are named additional Insureds as respects to Auto Liability per form issued
by the carrier, M2855A subject to policy terms and conditions. Waiver of subrogation applies.
CERTIFICATE Wni nE1z CANCELLATION
Jill 111111111111111111111111111111111111i�11�11111111111111111111
......:..:"*** "•**"**"`*'SNGLP 936 Tray 1 : Piece 249 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
249 1 SP 0.530 THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
City of Gilroy ACCORDANCE WITH THE POLICY PROVISIONS.
City Engineer Attn: Sara Soto AUTHORIZED REPRESENTATIVE
7351 Rosanna St
Gilroy CA 95020-6141
ACORD 25 (2016/03) O 1988-2015 ACORD CORPORATION. All rights reserved.
The ACORD name and logo are registered marks of ACORD
CMO CAD 5000921839 BALCH PETROLEUM CONTRACTOR ANQ EFFECTIVE: 10/15/2020 PROCESSED: 10/14/2020
,m,. OREGON MUTUAL INSURANCE COMPANY M2855A (8-19)
COMMERCIAL AUTO CLUSTER ENDORSEMENT
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
This endorsement modifies insurance provided under the following:
BUSINESS AUTO COVERAGE FORM
VV iith respect to coverage provided by this endorsement, the provisions of the Business Auto Coverage Form apply
unless modified by this endorsement.
COVERAGE SUMMARY
This is a summary of the coverages provided by this
endorsement.
1. Bail Bonds........................................................1
2. Broadened Pollution.........................................1
3. Business Property of Others .............................1
4. Employees as Insureds, OtherThan Retail
Delivery............................................................1
8. Glass Repair Deductible Waiver.......................1
6. Hired Auto Loss of Use.....................................1
7. Hired Auto Physical Damage ............................1
8. Loan Lease Gap...............................................2
9. Personal Effects...............................................2
10. Rental Reimbursement.....................................2
11. Towing............................................................2
12. Additional Insured by Contract or Agreement....2
13. Waiver of Subrogation by Contract
orAgreement ...................................................
3
1. Bail Bonds
Section III — Liability Coverage, A. Coverage, 2.
Coverage Extensions, a. Supplementary Payments,
Paragraph (2) is replaced with the following:
(2) Up to $2,500 for cost of bail bonds (including
bonds for related traffic law violations)
required because of an "accident" we cover.
We do not have to furnish these bonds.
2. Broadened Pollution
The following is added to Section II — Liability
Coverage, B. Exclusions,11. Pollution:
Paragraphs a. and b. above do not apply to
"accidents" that occur away from premises
owned by or rented to an "insured" with respect
to "pollutants" carried in or upon a covered
"auto" up to the first $1,000 of damage for any
one "accident".
3. Business Property of Others
The following is added to Section II — Liability
Coverage, B. Exclusions, 6. Care, Custody or
Control:
This exclusion does not apply to "property
damage" to property of others up to an amount
not exceeding $1,000 in any one "accident'.
Coverage is excess over any other valid and
collectible insurance.
4. Employees as Insureds, Other Than Retail
Delivery
The following is added to Section II — Liability
Coverage, A. Coverage, 1. Who Is An Insured:
An "employee" of yours is an "insured" while
using a covered "auto" you do not own, hire or
borrow in your business or your personal affairs.
However, this paragraph does not apply to
"auto" used for retail delivery.
5. Glass Repair Deductible Waiver
The following is added to Section III — Physical
Damage Coverage, A. Coverage, 3. a. Glass
breakage:
No deductible applies if glass damage is
repaired rather than replaced.
6. Hired Auto Loss of Use
Section III — Physical Damage Coverage, A.
Coverage, 4. Coverage Extensions, b. Loss Of Use
Expenses, the last sentence is replaced with:
However, the most we will pay for any expenses
for loss of use is $78 per day, to a maximum of
$1,000.
7. Hired Auto Physical Damage
The following is added to Section III — Physical
Damage Coverage, A. Coverage, 4. Coverage
Extensions:
Hired Auto Physical Damage
If a Covered Auto Designation Symbol 1 or 8
applies to Liability Coverage, and if at least one
covered "auto" you own is covered for
Comprehensive or Specified Causes of Loss
and Collision coverage, then the physical
damage coverage provided extends to those
"autos" you lease, hire, rent or borrow. This
does not include any "auto" you lease, hire, rent
or borrow from any of your "employees",
partners (if you are a partnership), members (if
you are a limited liability company) or members
of their households. The deductible will be equal
to the highest deductible applicable to covered
"autos" you own.
Includes copyrighted material of Insurance Services Office, Inc., with its permission
IU2855A (8-19) Page 1 of 3 ?9m21 rRM
The most we will pay under this coverage is
the least of:
1. $50,000; or
2. The actual value at the time of loss; or
3. The cost of repairing or replacing the
damaged or stolen property with other
property of like kind or quality.
B. Loan Lease Gap
The following is added to Section III — Physical
Damage Coverage, A. Coverage:
Loan Lease Gap
In the event of a total "loss" to a covered "auto"
that is covered for Comprehensive or Specked
Causes of Loss and Collision coverage, we will
pay the "outstanding balance" on the lease or
loan for that covered "auto" up to $2,500.
9. Personal Effects
The following is added to Section III — Physical
Damage Coverage, A. Coverage, 4. Coverage
Extensions:
Personal Effects
For any owned "auto" that is involved in a
covered 'loss", we will pay up to 5500 for
"personal effects" that are lost or damaged as a
result of the covered "loss", without applying a
deductible.
10. Rental Reimbursement
The following is added to Section III — Physical
Damage Coverage, A. Coverage, 4. Coverage
Extensions:
Rental Reimbursement
If a covered "auto" owned by you is covered for
Comprehensive or Specified Causes of Loss
and Collision coverage, we will pay for rental
reimbursement expenses incurred by you for the
rental of an "auto" because of "loss" to a
covered "auto". Payment applies in addition to
the otherwise applicable amount of each
coverage you have on a covered "auto". No
deductibles apply to this coverage.
We will pay only for those expenses incurred
during the policy period beginning 24 hours after
the "loss" and ending, regardless of the policy's
expiration, with the lesser of the following
number of days:
1. The number of days reasonably required to
repair or replace the covered "auto". If "loss"
is caused by theft, this number of days is
added to the number of days it takes to
locate the covered "auto" and return it to
you, or
2. Up to $75 per day up to 30 calendar days.
This coverage does not apply while there
are spare or reserve "autos" available to you
for your operations.
if "loss" results from the total theft of a
covered "auto" of the private passenger
type, we will pay under this coverage only
that amount of your rental reimbursement
expenses which is not already provided for
under another Physical Damage Coverage
Extension.
11. Towing
Section III — Physical Damage Coverage, A.
Coverage, 2. Towing is replaced with the following:
We will pay up to $100 for towing and labor
costs incurred each time a covered "auto" of the
private passenger or Light Local Service
(0—10,000 lbs. GWV) type is disabled.
However, the labor must be performed at the
place of disablement.
12. Additional Insured by Contract or Agreement
A. The following is added to Section II — Liability
Coverage, A. Coverage, 1. Who Is An Insured:
When you have agreed in a written contract
or agreement to include a person or
organization as an additional "insured", such
person or organization is included as an
"insured" subject to the following:
1. Such person or organization is an
additional "insured" only to the extent
such person or organization is liable for
"bodily injury" or "property damage"
because of the conduct of an "insured"
under Paragraphs a. or b. under Section
11— Liability Coverage, Paragraph M.
Who Is An Insured, caused by an
"accident" and resulting from the
ownership, maintenance or use of a
covered "auto"; andITD111To21
2. The written contract or agreement
described above must have been
executed prior to the "accident" that
caused the "bodily injury" or "property
damage" and be in effect at the time of
such "accident": and
3. The insurance afforded to any such
additional "insured" does not apply to
any "accident" beyond the period of time
required by the written contract or
agreement described above.
B. The most we will pay on behalf of such
additional "insured(s)" is the lesser of:
1. The Limits of Insurance specified in the
written contract or agreement described
above; or
Includes copyrighted material of Insurance Services Office, Inc., with its permission
M2855A (8-19) Page 2 of 3 1OC322 FRM
2. The Limits of Insurance shown in the
Declarations.
This provision shall not increase the Limit of
Insurance shown in the Declarations in this
policy or coverage part.
C. The following change is made to Section ill —
Liability Coverage, A. Coverage,1. Who is An
Insured:
Paragraph 1.c. is deleted in its entirety.
D. The following changes are made to Section IV —
Business Auto Conditions, B. General
Conditions, Paragraph 5.Other Insurance:
1. The following is added to Paragraph 5.a.:
If required by the written contract or
agreement described above. the insurance
afforded to the additional "insured" under
this provision will be primary to, and will not
seek contribution from, the additional
"insured's" own insurance.
2. Paragraph 5.c. is deleted in its entirety.
E. Section V — Definitions, "insured contract" is
amended to add the following:
An "insured contract" does not include that
part of any contract or agreement:
That pertains to the ownership,
maintenance or use of an "auto" and
which indemnifies a person or
organization for other than the vicarious
liability of such person or organization
for "bodily injury" or "property damage"
caused by your operation or use of a
covered "auto".
However, a person or organization is an
additional "insured" under this provision
only to the extent such person or
organization is not named as an
"insured" by separate endorsement to
this policy.
13. Waiver of Subrogation by Contract or Agreement
The following is added to Section IV — Business
Auto Conditions, A. Loss Conditions, Paragraph S.
Transfer Of Rights Of Recovery Against Others To
Us:
We waive any right of recovery we have against
a person or organization because of payments
we make for "bodily injury" or "property damage"
when you and such person or organization have
agreed in writing in a contract or agreement to
waive such right of recovery. provided:
1. Such written contract or agreement was:
a. Made prior to the "accident" or "loss"
resulting in the covered "bodily injury" or
"property damage"; and
b. Was in effect at the time of the covered
"bodily injury" or "property damage".
2. The covered "bodily injury" or "property
damage" must arise out of the operations
specified in such written contract or
agreement.
3. At our request you must provide us with a
copy of the aforementioned written contract
or agreement.
Additional Definitions
The following Paragraphs are added to Section V —
Definitions:
Q. "Personal effects" means your tangible property
that is worn or carried by you, except tools,
jewelry, money or securities.
R. "Outstanding balance" means the amount you
owe on the lease or loan at the time of the "loss"
less any overdue lease/loan payments, security
deposits not returned by the lessor, costs for
extended warranties or insurance purchased
with the loan or lease, or carry-over balances
from previous loans or teases.
Includes copyrighted material of Insurance Services Orrice. Inc., with its permission
M2855A (8-19) Page 3 of 3 79¢,231'HtA