Loading...
COI - Dudek - Expires 2024-08-28ACC7RD® CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DD/YYYY) 8/28/2024 08/23/2023 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 Lockton Companies 444 W. 47th Street, Suite 900 Kansas City MO 64112-1906 (816) 960-9000 kcasu@lockton.com INSURED DUDEK 1475279 605 THIRD STREET ENCINITAS CA 92024 CONTACT NAME: IPHONE FAX (A/C. No. Extl: (A/C. No): IE-MAIL ADDRESS: INSURER(S) AFFORDING COVERAGE INSURER A: Zurich American Insurance Company INSURER : American Guarantee and Liab. Ins. Co. INSURERC: Continental Casualty Company_ INSURER D : INSURER E : INSURER F NAIC # 16535 26247 20443 COVERAGES CERTIFICATE NUMBER: 18591893 REVISION NUMBER: XXXXXXX 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 A _L THE TERMS. EXCLUSIONS AND CON DITIC NS CF SUCH POLICIES. LIMITS SHOW \I MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR ADDL SUBR POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER (MM/DD/YYYYI (MM/DD/YYYY) LIMITS A X COMMERCIAL GENERAL LIABILITY GL00146311 08/28/2023 08/28/2024 EACH OCCURRENCE CLAIMS -MADE X OCCUR GEI I'L AGGREGATE LIMIT APPLIES PER: POLICY PRO- JECT X LOC OTHER: A AUTOMOBILE LIABILITY X ANY AUTO OWNED SCHEDULED AUTOS ONLY AUTOS HIRED NON -OWNED AUTOS ONLY AUTOS ONLY B A C X X UMBRELLA LIAB X EXCESS LIAB OCCUR CLAIMS -MADE DED RETENTION $ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICERIMEMBER EXCLUDED? (Mandatory In NH) If yes, describe under DESCRIPTION OF OPERATIONS below PROFESSIONAL LIABILITY INCLUDES POLLUTION Y/N Y Y Y Y Y Y NIA Y N N BAP0146329 AUC0146407 WC0146330 DAMAGE TO RENTED PREMISES (Ea occurrence( MED EXP (Arw one person) PERSONAL & ADV INJURY GENERAL AGGREGATE PRODUCTS - COMP/OP AGG $ 1.000.000 $ 100.000 $ 10.000 $ 1.000,000 $ 2,000.000•- $ 2,000.000 08/28/2023 08/28/2024(EeaocldeDSINGLELIMIT $ 1,000,000 'BODILY INJURY (Per person) $ XXXXXXX 'BODILY INJURY (Per accident) $ XXXXXXX I(Per acciPROPERdTYent)DAMAGE $ XXXXXXX $ XXXXXXX 08/28/2023 08/28/2024 EACH OCCURRENCE $ 5,000,000 (AGGREGATE $ 5,000,000 $ XXXXXXX X I STATUTE I Pa - 08/28/2023 08/28/2024 EEH591932835 INCL POLL 08/28/2023 08/28/2024 E.L. EACH ACCIDENT $ 1 ,000,000 E.L. DISEASE - EA EMPLOYEE $ 1 ,000,000 E.L. DISEASE - POLICY LIMIT $ 1 .000.000 PER CLAIM $5 000,000 AGGREGATE $5,000,000 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached If more space is required) ALL OPERATIONS; GENERAL LIABILITY AND AUTO LIABILITY ARE PRIMARY AND NON-CONTRIBUTORY. CITY OF GILROY, ITS OFFICERS, OFFICIALS AND EMPLOYEES ARE INCLUDED AS AN ADDITIONAL INSURED ON THE GENERAL LIABILITY, UMBRELLA, AND AUTO LIABILITY POLICIES. WAIVER OF SUBROGATION IN FAVOR OF THE ADDITIONAL INSURED ON THE GENERAL LIABILITY, UMBRELLA, AUTO LIABILITY, AND WORKER'S COMPENSATION POLICIES. 30 DAY NOTICE OF CANCELLATION APPLIES, 10 DAYS NOTICE FOR NON-PAYMENT OF PREMIUM. CERTIFICATE HOLDER 18591893 CITY OF GILROY, ITS OFFICERS, OFFICIALS AND EMPLOYEES 7351 ROSANNA STREET GILROY CA 95020 CANCELLATION See Attachments 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 /111 *411 Ati © 1988-2015 ACORD CORPORATION. All rights reserved ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD Attachment Code : D574649 Certificate ID : 18591893 Additional Insured — Owners, Lessees Or Contractors — Scheduled Person Or Organization THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. Policy No. GL00146311 Effective Date: 08/28/2023 This endorsement modifies insurance provided under the: Commercial General Liability Coverage Part SCHEDULE Name Of Additional Insured Person(s) Or Organization(s): ANY PERSON OR ORGANIZATION ARE REQUIRED ALL TO PROVIDE ADDITIONAL INSURED STATUS IN LOCATIONS A WRITTEN CONTRACT, AGREEMENT OR PERMIT. Includes copyrighted material of Insurance Services Office, Inc., with its permission. ZURICH Location(s) Of Covered Operations U-GL-2169-A CW (02/19) Page 1 of 2 Attachment Code : D574649 Certificate ID : 18591893 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 of this endorsement, but only with respect to liability for "bodily injury", "property damage" or "personal and advertising injury" caused, in whole or in part, by: 1. Your acts or omissions; or 2. The acts or omissions of those acting on your behalf; in the performance of your ongoing operations for the additional insured(s) at the location(s) designated in such Schedule. B. With respect to the insurance afforded to these additional insureds, the following additional exclusions apply: This insurance does not apply to "bodily injury" or "property damage" occurring after: 1. All work, including materials, parts or equipment furnished in connection with such work, on the project (other than service, maintenance or repairs) to be performed by or on behalf of the additional insured(s) at the location of the covered operations has been completed; or 2. That portion of "your work" out of which the injury or damage arises has been put to its intended use by any person or organization other than another contractor or subcontractor engaged in performing operations for a principal as a part of the same project. All other terms, conditions, provisions and exclusions of this policy remain the same. U-GL-2169-A CW (02/19) Page 2 of 2 Includes copyrighted material of Insurance Services Office, Inc., with its permission. Attagjryi RiptEC3WMONcaCESBS LIABILITY INSURANCE POLICY WC 00 03 13 WC0146330 Dudek 08/28/202308/28/2024 (Ed. 4-84) WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT 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.) This agreement shall not operate directly or indirectly to benefit anyone not named in the Schedule. Schedule ANY PERSON OR ORGANIZATION YOU ARE REQUIRED TO WAIVE YOUR RIGHTS OF RECOVERY IN A WRITTEN CONTRACT, AGREEMENT OR PERMIT WITH THE NAMED INSURED. WC000313 (Ed. 4-84) 0 1983 National Council on Compensation Insurance. Attachment Code : D574648 Certificate ID : 18591893 Waiver Of Subrogation (Blanket) Endorsement Policy No. Eff, Date of Pot, Exp. Date of Pol. Eff. Date of End. Producer Add'l Prem. Return Prem. GL00146311 08/28/2023 08/28/2024 08/28/2024 37385000 $ $ INC THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. This endorsement modifies insurance provided under the: Commercial General Liability Coverage Part The following is added to the Transfer Of Rights Of Recovery Against Others To Us Condition: If you are required by a written contract or agreement, which is executed before a loss, to waive your rights of recovery from others, we agree to waive our rights of recovery. This waiver of rights shall not be construed to be a waiver with respect to any other operations in which the insured has no contractual interest. U-GL-925-B CW (12/01) Attachment Code : D574648 Certificate ID : 18591893 Page 1 of 1 Attachment Code : D574651 Certificate ID : 18591893 POLICY NUMBER: BAP0146329 COMMERCIAL AUTO CA20481013 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. DESIGNATED INSURED FOR COVERED AUTOS LIABILITY COVERAGE This endorsement modifies insurance provided under the following: AUTO DEALERS COVERAGE FORM BUSINESS AUTO COVERAGE FORM MOTOR CARRIER COVERAGE FORM With respect to coverage provided by this endorsement, the provisions of the Coverage Form apply unless modified by this endorsement. This endorsement identifies person(s) or organization(s) who are "insureds" for Covered Autos Liability Coverage under the Who Is An Insured provision of the Coverage Form. This endorsement does not alter coverage provided in the Coverage Form. This endorsement changes the policy effective on the inception date of the policy unless another date is indicated below. Named Insured: DUDEK Endorsement Effective Date: 08/28/2023 SCHEDULE Name Of Person(s) Or Organization(s): ANY PERSON OR ORGANIZATION TO WHOM OR WHICH YOU ARE REQUIRED TO PROVIDE ADDITIONAL INSURED STATUS OR ADDITIONAL INSURED STATUS ON A PRIMARY, NON-CONTRIBUTORY BASIS, IN A WRITTEN CONTRACT OR WRITTEN AGREEMENT EXECUTED PRIOR TO LOSS, EXCEPT WHERE SUCH CONTRACT OR AGREEMENT IS PROHIBITED BY LAW. Information reauired to complete this Schedule. if not shown above. will be shown in the Declarations. CA 20 48 10 13 © Insurance Services Office, Inc., 2011 Page 1 of 2 Attachment Code : D574651 Certificate ID : 18591893 Each person or organization shown in the Schedule is an "insured" for Covered Autos Liability Coverage, but only to the extent that person or organization qualifies as an "insured" under the Who Is An Insured provision contained in Paragraph A.1. of Section II — Covered Autos Liability Coverage in the Business Auto and Motor Carrier Coverage Forms and Paragraph D.2. of Section I — Covered Autos Coverages of the Auto Dealers Coverage Form. CA20481013 © Insurance Services Office, Inc., 2011 Page 2 of 2 Attach eigg9(4100§ ,6§IA Ug ID : 18591893 COMMERCIAL AUTO CA04441013 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. WAIVER OF TRANSFER OF RIGHTS OF RECOVERY AGAINST OTHERS TO US (WAIVER OF SUBROGATION) This endorsement modifies insurance provided under the following: AUTO DEALERS COVERAGE FORM BUSINESS AUTO COVERAGE FORM MOTOR CARRIER COVERAGE FORM With respect to coverage provided by this endorsement, the provisions of the Coverage Form apply unless modified by the endorsement. This endorsement changes the policy effective on the inception date of the policy unless another date is indicated below. Named Insured: DUDEK Endorsement Effective Date: 08/28/2023 SCHEDULE Name(s) Of Person(s) Or Organization(s): ANY PERSON OR ORGANIZATION YOU ARE REQUIRED TO WAIVE YOUR RIGHTS OF RECOVERY IN A WRITTEN CONTRACT, AGREEMENT OR PERMIT WITH THE NAMED INSURED. Information required to complete this Schedule, if not shown above, will be shown in the Declarations. The Transfer Of Rights Of Recovery Against Others To Us condition does not apply to the person(s) or organization(s) shown in the Schedule, but only to the extent that subrogation is waived prior to the "accident" or the "loss" under a contract with that person or organization. CA 04 44 10 13 © Insurance Services Office, Inc., 2011 Page 1 of 1 Attachment Code : D589214 Certificate ID : 18591893 Other Insurance Amendment — Primary And Non -Contributory Policy No. GL00146311 Eff. Date of Pol. 08/28/2023 Exp. Date of Pol. 08/28/2024 Eff. Date of End. 08/28/2023 Producer No. 37385000 Add'1. Prem INCL ZURICH w, THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. Named Insured: DUDEK Address (including ZIP Code): 605 THIRD STREET ENCINITAS CA92024 This endorsement modifies insurance provided under the: Commercial General Liability Coverage Part Return Prem. I l 1. The following paragraph is added to the Other Insurance Condition of Section IV — Commercial General Liability Conditions: This insurance is primary insurance to and will not seek contribution from any other insurance available to an additional insured under this policy provided that: a. The additional insured is a Named Insured under such other insurance; and b. You are required by a written contract or written agreement that this insurance would be primary and would not seek contribution from any other insurance available to the additional insured. 2. The following paragraph is added to Paragraph 4.b. of the Other Insurance Condition of Section IV — Commercial General Liability Conditions: This insurance is excess over: Any of the other insurance, whether primary, excess, contingent or on any other basis, available to an additional insured, in which the additional insured on our policy is also covered as an additional insured on another policy providing coverage for the same "occurrence", offense, claim or "suit". This provision does not apply to any policy in which the additional insured is a Named Insured on such other policy and where our policy is required by written contract or written agreement to provide coverage to the additional insured on a primary and non-contributory basis. All other terms and conditions of this policy remain unchanged. U-GL-1327-B CW (04/13) Page 1 of 1 Includes copyrighted material of Insurance Services Office, Inc., with its permission. Attachment Code : D580830 Certificate ID : 18591893 Additional Insured — Owners, Lessees Or Contractors — Completed Operations THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. Policy No. GL00146311 This endorsement modifies insurance provided under the: Commercial General Liability Coverage Part Name Of Additional Insured Person(s) Or Organization(s): ANY PERSON OR ORGANIZATION ARE REQUIRED ALL TO PROVIDE ADDITIONAL INSURED STATUS IN LOCATIONS A WRITTEN CONTRACT, AGREEMENT OR PERMIT. Effective Date: 08/28/2023 SCHEDULE ZURICH Location And Description Of Completed Operations Includes copyrighted material of Insurance Services Office, Inc., with its permission. U-GL-2168-A CW (02/19) Attachment Code : D580830 Certificate ID : 18591893 Section II — Who Is An Insured is amended to include as an additional insured the person(s) or organization(s) shown in the Schedule of this endorsement, but only with respect to liability for "bodily injury" or "property damage" caused, in whole or in part, by "your work" at the location designated and described in such Schedule, performed for that additional insured and included in the "products -completed operations hazard". All other terms, conditions, provisions and exclusions of this policy remain the same. U-GL-2168-A CW (02/19) Includes copyrighted material of Insurance Services Office, Inc., with its permission.