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COI - Youth Alliance - Expires 2024-11-16SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. INSURER(S) AFFORDING COVERAGE INSURER F : INSURER E : INSURER D : INSURER C : INSURER B : INSURER A : NAIC # NAME:CONTACT (A/C, No):FAX E-MAILADDRESS: PRODUCER (A/C, No, Ext):PHONE INSURED REVISION NUMBER:CERTIFICATE NUMBER:COVERAGES 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). 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. OTHER: (Per accident) (Ea accident) $ $ N / A SUBR WVD ADDL INSD 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. $ $ $ $PROPERTY DAMAGE BODILY INJURY (Per accident) BODILY INJURY (Per person) COMBINED SINGLE LIMIT AUTOS ONLY AUTOSAUTOS ONLY NON-OWNED SCHEDULEDOWNED ANY AUTO AUTOMOBILE LIABILITY Y / N WORKERS COMPENSATION AND EMPLOYERS' LIABILITY OFFICER/MEMBER EXCLUDED? (Mandatory in NH) DESCRIPTION OF OPERATIONS below If yes, describe under ANY PROPRIETOR/PARTNER/EXECUTIVE $ $ $ E.L. DISEASE - POLICY LIMIT E.L. DISEASE - EA EMPLOYEE E.L. EACH ACCIDENT EROTH-STATUTEPER LIMITS(MM/DD/YYYY)POLICY EXP(MM/DD/YYYY)POLICY EFFPOLICY NUMBERTYPE OF INSURANCELTRINSR DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) EXCESS LIAB UMBRELLA LIAB $EACH OCCURRENCE $AGGREGATE $ OCCUR CLAIMS-MADE DED RETENTION $ $PRODUCTS - COMP/OP AGG $GENERAL AGGREGATE $PERSONAL & ADV INJURY $MED EXP (Any one person) $EACH OCCURRENCE DAMAGE TO RENTED $PREMISES (Ea occurrence) COMMERCIAL GENERAL LIABILITY CLAIMS-MADE OCCUR GEN'L AGGREGATE LIMIT APPLIES PER: POLICY PRO-JECT LOC CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DD/YYYY) CANCELLATION AUTHORIZED REPRESENTATIVE ACORD 25 (2016/03) © 1988-2015 ACORD CORPORATION. All rights reserved. CERTIFICATE HOLDER The ACORD name and logo are registered marks of ACORD HIRED AUTOS ONLY 8/16/2023 Pacific Diversified Insurance Services 15005 Concord Circle Suite 110 Morgan Hill CA 95037 Kimberly D.White,CISR 408-842-2131 408-842-0867 kwhite@pdins.com License#:0K07568 Nonprofits Insurance Alliance of California YOUTALL-01 American Guarantee &Liability Insurance Company 26247HollisterYouthAlliance 301 4th St.,Suite #101 Hollister CA 95024-1291 1237622866 A X 1,000,000 X 500,000 X Liquor Liability 20,000 1,000,000 2,000,000 X 2022-06291 11/16/2022 11/16/2023 2,000,000 Liquor Liability 1,000,000 A 1,000,000 X X 2022-06291 11/16/2022 11/16/2023 A X X 3,000,0002022-06291-UMB 11/16/2022 11/16/2023 3,000,000 X 0 B X Y WC571027107 4/1/2023 4/1/2024 1,000,000 1,000,000 1,000,000 A Professional Liability Improp Sexual Liab Property-Special/Replacement Cvrg 2022-06291 11/16/2022 11/16/2023 Deductible $250 1,000,000 1,000,000 $35,000 Certificate holders are named as additional insured as per written contracts and/or agreements,per carrier's blanket endorsements attached.30 days notice of cancellation for legal notices,except for non-payment,which is a 10 day notice. Youth Alliance will provide social justice youth leadership development services to impacted South Santa Clara County youth populations.YA will provide case management support,systems navigation,mentorship,and re-entry planning for a maximum of 24 referred South County youth (ages 11-18)in Gilroy (12)and Morgan Hill (12)annually.YA will also support SCYTF by providing late-night educational activities and identifying healthy and restorative events for youth to increase and develop their leadership skills. 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,QVXUDQFH6HUYLFHV2IILFH,QF 3DJHRI&* DocuSign Envelope ID: D63A0D64-5025-4720-B0B3-9DCC85A24289 +ROOLVWHU<RXWK$OOLDQFH1$0(',1685(' )2501,$&(32/,&<180%(5 7+,6(1'256(0(17&+$1*(67+(32/,&<3/($6(5($',7&$5()8//< :$,9(52)75$16)(52)5,*+762)5(&29(5< $*$,16727+(56:$,9(52)68%52*$7,21 &200(5&,$/*(1(5$//,$%,/,7<&29(5$*(3$57 62&,$/6(59,&(352)(66,21$//,$%,/,7<&29(5$*()250 7KLVHQGRUVHPHQWPRGLILHVLQVXUDQFHSURYLGHGXQGHUWKHIROORZLQJ 1DPHRI3HUVRQRU2UJDQL]DWLRQ 6&+('8/( :KHUH\RXDUHVRUHTXLUHGLQDZULWWHQFRQWUDFWRUDJUHHPHQWFXUUHQWO\LQHIIHFWRUEHFRPLQJHIIHFWLYHGXULQJWKH WHUPRIWKLVSROLF\ZHZDLYHDQ\ULJKWRIUHFRYHU\ZHPD\KDYHDJDLQVWWKDWSHUVRQRURUJDQL]DWLRQZKRPD\EH QDPHGLQWKHVFKHGXOHDERYHEHFDXVHRISD\PHQWVZHPDNHIRULQMXU\RUGDPDJH 3DJHRI1,$&( DocuSign Envelope ID: D63A0D64-5025-4720-B0B3-9DCC85A24289 WORKERS’ COMPENSATION AND EMPLOYERS’ LIABILITY INSURANCE POLICY WC 04 03 06 (Ed. 4 84) Schedule WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT—CALIFORNIA This endorsement changes the policy to which it is attached effective on the inception date of the policy unless a different date is indicated below. (The following “attaching clause” need be completed only when this endorsement is issued subsequent to preparation of the policy.) This endorsement, effective on 04/01/2023 at 12:01 A.M. standard time, forms a part of (DATE) Policy No.WC 5710271 - 07 Endorsement No. of the American Guarantee and Liability Insurance Company (NAME OF INSURANCE COMPANY) issued to Hollister Youth Alliance Premium (if any) $_____________________________________________ Authorized Representative 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.) You must maintain payroll records accurately segregating the remuneration of your employees while engaged in the work described in the Schedule. The additional premium for this endorsement shall be %of the California workers’compensation premium otherwise due on such remuneration Person or Organization Job Description All persons and/or organizations that are required by written contract or agreement with the insured, executed prior to the accident or loss, that waiver of subrogation be provided under this policy for work performed by you for that person and/or organization. WC 04 03 06 (Ed. 4-84)Page 1 of 1 DocuSign Envelope ID: D63A0D64-5025-4720-B0B3-9DCC85A24289