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COI - Live Oak Adult Day Services - Expires 2022-09-10OP ID: TT2 .A� R� CERTIFICATE OF LIABILITY INSURANCE DA0811712021TE Y) 08117/2021 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 San Jose Insurance Agency NAAME CT Tina Tremani X340 PHONE FAX sA/c No EXt:408-371-3700 A1c No): E-MAIL ADDRESS: tina@sanjoseins.com PRODUCER CUSTOMER ID #: LIVEO.S INSURER(S) AFFORDING COVERAGE NAIC # INSURED Live Oak Adult Day Services, I 1147 Minnesota Ave San Jose, CA 95125 INSURER A: Nonprofit Ins Alliance of Ca 11384 INSURER B: State Compensation Insurance 35076 INSURER C : INSURER D : 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 LTR TYPE OF INSURANCE P4DDL SUBR I POLICY NUMBER POLICY EFF MM/DD/YYYY POLICY EXP MMIDDIYYYY LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 1,000,00 A X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE � OCCUR X 202101332NPO 09/10/2021 09/10/2022 PREMISES Ea occurrence $ 500►00 MED EXP (Any one person) $ 20,000 X Social Services 202101332NPO 09/10/2021 09/1012022 PERSONAL & ADV INJURY S 1,000,000 Professional GENERAL AGGREGATE $ 2,000,00 PRODUCTS - COMP/OP AGG $ 2,000,00 GEN'L AGGREGATE LIMIT APPLIES PER: PRO- LOC X POLICY JECT Agg Profe $ 3,000,00 A AUTOMOBILE LIABILITY ANY AUTO COMBINED SINGLE LIMIT (Ea accident) $ 1,000,00 BODILY INJURY (Per person) $ ALL OWNED AUTOS SCHEDULED AUTOS HIRED AUTOS No OWNED VEHICLES 202101332NPO 09/10/2021 09/10/2022 BODILY INJURY (Per accident} $ PROPERTY DAMAGE (PER ACCIDENT) $ X NON -OWNED AUTOS 202101332NPO 09/10/2021 09/10/2022 X $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ AGGREGATE S EXCESS LIAB CLAIMS -MADE DEDUCTIBLE S _ i $ RETENTION S t I B WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE Y 1 N OFFICE(Mandatory In ER EXCLUDED? F—IN (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below 1 A X 930114-21 07/01/2021 07/01/2022 X T RY LIMIT O R E.L. EACH ACCIDENT S 1,000,00 E.L. DISEASE - EA EMPLOYE $ 1,000,00 E.L. DISEASE - POLICY LIMIT $ 1,000,00 A Directors & Office 202101332DONPO 09/10/2021 09/10/2022 DOLI 1,000,000 A Employee Dishonest 202101332NPO 09/10/2021 09/10/2022 Crime 10,000 DESCRIPTION OF OPERATIONS / LOCATIONS 1 VEHICLES (Attach ACORD 101, Additional Remarks Schedule, If more space Is required) Adult day care and related services. Cityof Gilro , its OfIgers, Representatives, A ents & Employees are name as additional insured. Waiver Qf subrogationi� ap 19ies t9 workers com.p nsaiton in favor of The City of Gilroy as requiredpby written contract TOtays Notice for non-payment of premium %..Mr% I IrIVA 1 C nVLUCR GANGtLLA I IUN GILROY1 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE City of Gilroy, H.C.D. THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 7351 Rosanna St ACCORDANCE WITH THE POLICY PROVISIONS. Gilroy, CA 95020 AUTHORIZED REPRESENTATIVE I ©1988-2009 ACORD CORPORATION. All rights reserved. ACORD 25 (2009/09) The ACORD name and logo are registered marks of ACORD POLICY NUMBER: 2021-01332 Named Insured: Live Oak Adult Day Services, Inc. COMMERCIAL GENERAL LIABILITY CG20261219 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 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. I 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 ENDORSEMENT AGREEMENT BROKER COPY WAIVER OF SUBROGATION BLANKET BASIS HOME OFFICE SAN FRANCISCO EFFECTIVE JULY 1, 2021 AT 12.01 A.M. ALL EFFECTIVE DATES ARE AND EXPIRING JULY 11 2022 AT 12.01 A.M. 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 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 9301142-21 NEW 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 4 AUTHORIZED REPRESENT IVE SCIF FORM 10217 IREV.7-2014i JULY 15, 2021 r PRESIDENT AND CEO OLD DP 217