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HomeMy WebLinkAboutSouth Santa Clara County Fire District - Insurance CertificatesAC" �® CERTIFICATE OF LIABILITY INSURANCE DATE (MM 6/23/2017DnvYY) 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 Arthur J Gallagher & Co Insurance Brokers of CA. Inc License #0726293 CONTACT NAME PHONE FAX 415 - 546 9300 ,� 415 - 536 8499 E-MAIL DRESS , 1255 Battery Street #450 San Francisco CA 94111 INSURERS AFFORDING COVERAGE I NAIC # INSURER A Allied World Assurance Company Ltd EACH OCCURRENCE 81,000,000 INSURED F I REAG E -01 INSURER B 81,000,000 South Santa Clara County FPO 15670 Monterey Street Morgan Hill, CA 95037 INSURER C $10,000 INSURER D PERSONAL & ADV INJURY 1 $1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER X POLICY F7 PRO- JECT F7 LOC OTHER INSURER E $10,000,000 INSURER F $10,000,000 CDVFRArFC CFRTIFICATF IUI IMrario- 90023680 DF\/1CII 11U Iu1111AR170. 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. ILTR TYPE OF INSURANCE INSD WVD POLICY NUMBER MIWDDIYYYY MMIDDIYYYY LIMITS A X COMMERCIAL GENERAL LIABILITY _ CLAIMS -MADE FX OCCUR 0SIR Y 6300 - 0182 -01 7/1/2017 7/1/2018 EACH OCCURRENCE 81,000,000 ST0 RENTECi PREMISES Ea occurrence 81,000,000 X MED EXP (Any one person) $10,000 PERSONAL & ADV INJURY 1 $1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER X POLICY F7 PRO- JECT F7 LOC OTHER GENERAL AGGREGATE $10,000,000 PRODUCTS - COMP /OP AGG $10,000,000 $ AUTOMOBILE LIABILITY ANY AUTO OWNED SCHEDULED AUTOS ONLY AUTOS HIRED P1 NON -OWNED AUTOS ONLY AUTOS ONLY eMBINED ident) 5 $ BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ Per accident $ $ UMBRELLA LIAB EXCESS LIAB OCCUR CLAIMS -MADE EACH OCCURRENCE $ AGGREGATE $ DED RETENTION $ $ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y / N ANY PROPRIETOR /PARTNER /EXECUTIVE F7 OFFICER/MEMBER EXCLUDEI (Mandatory in NH) II yes, describe under DESCRIPTION OF OPERATIONS below NIA PER OTH- STATUTE ER E L EACH ACCIDENT $ E L DISEASE - EA EMPLOYEE $ E L DISEASE - POLICY LIMIT is DESCRIPTION OF OPERATIONS / LOCATIONS /VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached If more space Is required) City of Gilroy, Its Officers, Officials and Employees are also named as Additional Insureds as respects the shared of Battalion Chief Agreement. VGR I IV 11 ,M I C 11VLLOF-M trAFML LI_LA I IUIV City of Gilroy 7351 Rosanna Street Gilroy CA 95020 USA SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. REPRESENTATIVE 0 1988 -2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD POLICY NUMBER: 6300- 0182 -01 ADDITIONAL INSURED - DESIGNATED PERSON OR ORGANIZATION THIS ENDORSEMENT CHANGES THE COVERAGE FORM. PLEASE READ IT CAREFULLY. THIS ENDORSEMENT MODIFIES INSURANCE PROVIDED UNDER THE FOLLOWING: COMMERCIAL GENERAL LIABILITY COVERAGE FORM SCHEDULE Name of Additional Insured Person(s) or Organization(s): As required by written contract 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 in the performance of your ongoing or completed operations, or in connection with premises owned by or rented to you. ALL OTHER TERMS AND CONDITIONS REMAIN UNCHANGED. FR -GL 00008 00 (05115) Page 1 of 1 Includes copyrighted material of Insurance Services Offices, Inc. with its permission ACORO® �� CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DDnYYY) 7r6r2016 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 Arthur J. Gallagher & Co. Insurance Brokers of CA.Inc LIC #0726293 1255 Battery Street #450 CONTACT NAME: PHONE 415- 546 -9300 L9, 415 -536 -8499 E -MAIL INSURER AFFORDING COVERAGE NAICN San Francisco CA 94111 INSURER A: Allied World Assurance Company Ltd EACH OCCURRENCE $110001000 INSURED FI REAG E -01 INSURER B: $1,000,000 INSURER C: MED EXP (Any one person) South Santa Clara County FPD 15670 Monterey Street Morgan Hill, CA 95037 INSURER n: PERSONAL & ADV INJURY $1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: X POLICY ❑ JET 71 LOC OTHER: INSURER E $2,000,000 INSURER F: $2,000,000 COVERAGES CERTIFICATE NUMBER: 1234221311 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. LTTR L TYPE OF INSURANCE POLICY NUMBER POLICY E ICY EXP Lam A X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE X❑ OCCUR 0 SIR Y 6300 -0182 7/1/2016 7/1/2017 EACH OCCURRENCE $110001000 DAMAGE TO RENT PREMISES Ea occurrence $1,000,000 X MED EXP (Any one person) $5,000 PERSONAL & ADV INJURY $1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: X POLICY ❑ JET 71 LOC OTHER: GENERAL AGGREGATE $2,000,000 PRODUCTS - COMPIOP AGG $2,000,000 $ AUTOMOBILE LIABILITY ANY AUTO AUT OWNED AUTOSULED NON -OWNED HIRED AUTOS AUTOS Eaaccideru $ BODILY INJURY (Per person) S BODILY INJURY (Per accident) $ Per accideru $ E UMBRELLA LIAB EXCESS LIAB OCCUR CLAIMS -MADE EACH OCCURRENCE $ AGGREGATE $ DIED I I RETENTION $ $ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY YIN ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED'? (Mandatory in NH) 0 yes, describe under DESCRIPTION OF OPERATIONS below NIA PER OT STATUTE I ER E.L. EACH ACCIDENT $ E.L. DISEASE - EA EMPLOYEd $ E.L. DISEASE - POLICY LIMIT I S DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached If more space Is required) City of Gilroy, its Officers, Officials and Employees are also named as Additional Insureds as respects the shared of Battalion Chief Agreement. GLK 111- IL;A I L HULULK CANCELLATION City of Gilroy 7351 Rosanna Street Gilroy CA 95020 USA 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 nI.e'Yll,`j © 1988 -2014 ACORD CORPORATION. All rights reserved. ACORD 25 (2014/01) The ACORD name and logo are registered marks of ACORD POLICY NUMBER: 6300 -0182 ADDITIONAL INSURED - DESIGNATED PERSON OR ORGANIZATION THIS ENDORSEMENT CHANGES THE COVERAGE FORM. PLEASE READ IT CAREFULLY. THIS ENDORSEMENT MODIFIES INSURANCE PROVIDED UNDER THE FOLLOWING: COMMERCIAL GENERAL LIABILITY COVERAGE FORM SCHEDULE Name of Additional Insured Person(s) or Organization(s): As required by written contract 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 in the performance of your ongoing or completed operations, or in connection with premises owned by or rented to you. ALL OTHER TERMS AND CONDITIONS REMAIN UNCHANGED. FR-GL 00008 00 (05/15) Page 1 of 1 Includes copyrighted material of Insurance Services Offices, Inc. with its permission. P5261M128W2 Ale °® o6 25/20015 CERTIFICATE OF LIABILITY INSURANCE EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. 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 poiicy(les) 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 endorseme s . PRODUCER 0726293 1- 415 -546 -9300 CONTACT Arthur J. Gallagher & Co. NAME:_ PHONE ------- - - -_ -- FAX Insurance Brokers of California, Inc., License #0726293 lwc. Na..FaN:------ --- . - - - -- .----- - - -I_i '!��'--- .---- ---- ._ -___- 1255 Battery Street #450 E-MAIL ADnRESS:. San Francisco, CA 94111 INSURERS) AFFORDING COVERAGE NAIL 0 INSURERA: AMERICAN ALT INS CORP 19720 Loann Le INSURED - INSURERS: -- - - — - CLAIMS -MADE rg 1 OCCUR South Santa Clara County FPD -- — - - - - -- - -- INSURER C MED EJfP (An Y aie Pe—) INSURER 0 :__.______ 15670 Monterey Street INSURER E n__ -. -- ------- --- ------ ----- - - -- -- -- -- Morgan Hill, CA 95037 INSURER F PERSONAL &ADVINJURY COVERAGES CERTIFICATE NUMBER- 44345669 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,REOIJIREMENT, TERM OR CONDITION OF-ANY CONTRACTOR 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. R SUER I - -- - EFF POLICp� .POLICY NUMBER UMLICY LT LIMITS L TYPE OF INSURANCE 1M A GENERAL LIABILITY B VFI8 -TR- 0022468 -12 07/01/1 07/01/16 EACH OCCURRENCE $1,000,000 X COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED - - -- _PREMISES (Ea- occlurence)_ - - -- - - -- $ 1, 000, 000_ _ s5,000 CLAIMS -MADE rg 1 OCCUR MED EJfP (An Y aie Pe—) - -- -- $ 1,000,.000 X $0 SIR PERSONAL &ADVINJURY - -- ----------------- _ AGGREGATE $2,000,000 _GENERAL PRODUCTS - COMP /OP AGG $2.000.000 _ GEM LIMIT APPLIES PER L AGGREGATE -- - - - - -- $ -- --- -- I S POLICY PRO- LOC AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT ..(Ea acGdent) -- -- $ --- BODILY INJURY (Per person) $ I ANY AUTO - _ ALL OWNED I SCHEDULED AUTOS AUTOS BODILY INJURY (Per accident) $ — NON-OWNED _ PROPERTY DAMAGE $ — _ FIRED AUTOS _I AUTOS _I °�I-- - - -- -- - --- -. -- -- - $ UMBRELLA LIAB -- - OCCUR $ _EACH_OCCUR_RENCE AGGREGATE - -S -- - EXCESS LIAR CLAIMS -MADE DED RETENTION $ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y LN - __ TORY_LIMITS_ ___Ei_i_ - - - - -- ANY PROPRIETORIPARTNERIEXECUTIVE E.L. EACH ACCIDENT $ OFFICERIMEMBEREXCLUDED9 NIA A ---- ------ - - -- -- - . - - - -- (Mandatory In NH) E.L. DISEASE - EA EMPLOY $ 11 describe under - --- --- - -- - -- -- - - -- -- DESCRIPTION OF OPERATIONS belax E.L. DISEASE - POLICY LIMIT $ DESCRIPTION OF WERATIONS / LOCATIONS I VEHICLES (Anach ACORD 101, Additional Remarks Schedule, N more spec Is reputred) City of Gilroy, its Officers, Officials and Employees are also named as Additional Insureds as respects the shared of Battalion Chief Agreement. GtK 1 IF IGA I t MV LLILK GANGtLLA I IUN SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE City of Gilroy THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. 7351 Rosanna Street AUTHORIZED REPRESENTATIVE Gilroy, CA 95020 .f USA � 01988 -2010 ACORD CORPORATION. All rights reserved. ACORD 25 (2010105) The ACORD name and logo are registered marks of ACORD sumeshean 44345669 w N w O N 0 ono . 0 i N32W12K4 u2 x Policy Number: VFIS -TR- 0022468 -12 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. � N L+. ADDITIONAL INSURED - N DESIGNATED PERSON OR ORGANIZATION 0 0 This endorsement modifies insurance provided under the following: w GENERAL LIABILITY COVERAGE PART Name of person or organization: City of Gilroy, its Officers, Officials and Employees 7351 Rosanna Street Gilroy, CA 95020 [if no entry appears above, the information required to complete this endorsement will be shown in the Declarations as applicable to this endorsement.] SECTION II. WHO IS AN INSURED is amended to include as an insured the person or organization shown above, but only with respect to liability arising out of your operations or premises owned by or rented to you. VGL300 (03/03) Copyright 2002 American Alternative Insurance Corporation. All Page 1 of 1 rights reserved. Includes copyrighted material of the Insurance GENERAL LIABILITY Services Office, Inc. with its permission. DasCALIFORNIA D9PA1?tMBNT OF GENERAL SERVICES Governor Edmund G. grown Jr. July 1, 2014 STATE OF CALIFORNIA PUBLIC LIABILITY AND WORKERS' COMPENSATION INSURANCE FISCAL YEAR JULY 1, 20141 JUNE 30, 20'15 To Whom It May Concern: The State of California has elected to be self-Insured for general liability exposures. (Gov. Code section 990, at seq.) Under this form of Insurance, the State and its employees (as defined In Section 810.2 of the Government Code) are Insured for any tort liability, that may develop through the carrying out of official State activities and operations. All general liability tort claims against the State of California should be presented to the Victim Compensation and Government Claims Board, P.O. Box 3035, Sacramento, CA 958123035. (Gov. Code section 900, et. seq.) Internet link: www.vcgcb.ca.gov. In addition, the State of Callfomia has elected to be insured for motor vehicle liability exposures through a self - insurance program, administered by the Office of Risk and Insurance Management. Under this program, the Office of Risk and Insurance Management administers liability claims arising out of the operation of motor vehicles. This self - Insurance program and the protection it affords applies to vehicles owned and leased by the State of California. All motor vehicle liability tort claims against the State of California should be presented to. the Office of Risk and Insurance Management, P.O. Box 989052 MS -403, West Sacramento, CA 95798 9052, (800) 900 -3534. The State of California has a Master Agreement with the State Compensation Insurance Fund regarding workers' compensation benefits for all state employees, as required by the Labor Code. Sincerely, Dema Sandewmt Donna Sanderson Associate Risk Analyst (916) 376 -1621 donna. sanderson0das.ca.nov OFFICE OF RISK AND INSURANCE MANAGEMENT I State of Catlfomta I State Gonsurner Serv_ ices Agency 107 3rd Skeet, 1d Floor I West Sacramento, CA 95605 1 t 916,376.55021916.376.5275 CITY OF GILROY LIABILTIY RELEASE — AQUATICS EMPLOYMENT SKILLS TESTING Full Name of Participant: Home Address: City. Zip Code: Telephone: ( LIABILITY RELEASE NOTICE: THIS IS A LEGAL DOCUMENT WHICH LIMITS OUR LIABILITY. PLEASE READ CAREFULLY! By signing this document you state that: 1. You assume all risks of injuries from participation in this activity. 2. You release the City of Gilroy, its officers, employees, agents and servants from any and all liability arising out of your participation in this testing process. 3. If you are under 18, you must have this form signed by your parent /guardian. 4. In order to be considered for an Aquatics position with the city of Gilroy candidates must successfully pass a swim skills test. The swim skills test will consist of candidates showing their ability to swim continuously (up to 6 different strokes, 25 yards of each stroke depending on the position the candidate is applying for); tread water using only the legs (no arms or hands); complete a timed swim test to retrieve a 10 pound brick in 7 -10 feet of water and the ability to exit the pool without use of the steps or ladder. In addition, the candidate will be tested on their lifeguard rescue skills. City of Gilroy Liability Release (Aquatics) I. ASSUMPTION OF RISK: I voluntarily participate in the above described activity fully aware of the dangers and risks involved and knowing that the City of Gilroy does not guarantee the construction, condition, or safety of the facilities or the equipment, nor the supervision of the activity by its officers, employees, agents and servants. I expressly assume the risk of all loss, damage, or injury from my participation in or presence at the said activity. II. RELEASE OF LIABILITY: In consideration for the opportunity to participate in this activity and the services provided by the City of Gilroy, I (on behalf of myself; my heirs, assigns, and legal representatives) release the City of Gilroy, its officers, employees, agents and servants from any liability whatsoever arising out of any participation in or presence at the above activity. I expressly absolve the City of Gilroy, its officers, employees, agents and servants of liability for their negligence. PARTICIPANT SIGNATURE DATE Are you under 18 years of age? YES NO SIGNATURE OF PARENT OR GUARDIAN (required for participants under the age of 18) PRINT NAME OF PARENT OR GUARDIAN City of Gilroy Liability Release (Aquatics) CITY OF GILROY LIABILTIY RELEASE — AQUATICS EMPLOYMENT SKILLS TESTING Full Name of Participant: Home Address: City: Zip Code: Telephone: ( LIABILITY RELEASE NOTICE: THIS IS A LEGAL DOCUMENT WHICH LIMITS OUR LIABILITY. PLEASE READ CAREFULLY! By signing this document you state that: 1. You assume all risks of injuries from participation in this activity. 2. You release the City of Gilroy, its officers, employees, agents and servants from any and all liability arising out of your participation in this testing process. 3. If you are under 18, you must have this form signed by your parent /guardian. 4. In order to be considered for an Aquatics position with the city of Gilroy candidates must successfully pass a swim skills test. The swim skills test will consist of candidates showing their ability to swim continuously (up to 6 different strokes, 25 yards of each stroke depending on the position the candidate is applying for); tread water using only the legs (no arms or hands); complete a timed swim test to retrieve a 10 pound brick in 7 -10 feet of water and the ability to exit the pool without use of the steps or ladder. In addition, the candidate will be tested on their lifeguard rescue skills. City of Gilroy Liability Release (Aquatics) I. ASSUMPTION OF RISK: I voluntarily participate in the above described activity fully aware of the dangers and risks involved and knowing that the City of Gilroy does not guarantee the construction, condition, or safety of the facilities or the equipment, nor the supervision of the activity by its officers, employees, agents and servants. I expressly assume the risk of all loss, damage, or injury from my participation in or presence at the said activity. II. RELEASE OF LIABILITY: In consideration for the opportunity to participate in this activity and the services provided by the City of Gilroy, I (on behalf of myself, my heirs, assigns, and legal representatives) release the City of Gilroy, its officers, employees, agents and servants from any liability whatsoever arising out of any participation in or presence at the above activity. I expressly absolve the City of Gilroy, its officers, employees, agents and servants of liability for their negligence. PARTICIPANT SIGNATURE DATE Are you under 18 years of age? YES NO SIGNATURE OF PARENT OR GUARDIAN (required for participants under the age of 18) PRINT NAME OF PARENT OR GUARDIAN City of Gilroy Liability Release (Aquatics) CITY OF GILROY LIABILTIY RELEASE — AQUATICS EMPLOYMENT SKILLS TESTING Full Name of Participant: Home Address: City: Zip Code: Telephone: ( ) LIABILITY RELEASE NOTICE: THIS IS A LEGAL DOCUMENT WHICH LIMITS OUR LIABILITY. PLEASE READ CAREFULLY! By signing this document you state that: 1. You assume all risks of injuries from participation in this activity. 2. You release the City of Gilroy, its officers, employees, agents and servants from any and all liability arising out of your participation in this testing process. 3. If you are under 18, you must have this form signed by your parent /guardian. 4. In order to be considered for an Aquatics position with the city of Gilroy candidates must successfully pass a swim skills test. 5. The swim skills test will consist of candidates showing their ability to swim continuously (up to 6 different strokes, 25 yards of each stroke depending on the position the candidate is applying for); tread water using only the legs (no arms or hands); complete a timed swim test to retrieve a 10 pound brick in 7 -10 feet of water and the ability to exit the pool without use of the steps or ladder. In addition, the candidate will be tested on their lifeguard rescue skills. City of Gilroy Liability Release (Aquatics) ASSUMPTION OF RISK: I voluntarily participate in the above described activity fully aware of the dangers and risks involved and knowing that the City of Gilroy does not guarantee the construction, condition, or safety of the facilities or the equipment, nor the supervision of the activity by its officers, employees, agents and servants. I expressly assume the risk of all loss, damage, or injury from my participation in or presence at the said activity. II. RELEASE OF LIABILITY: In consideration for the opportunity to participate in this activity and the services provided by the City of Gilroy, I (on behalf of myself, my heirs, assigns, and legal representatives) release the City of Gilroy, its officers, employees, agents and servants from any liability whatsoever arising out of any participation in or presence at the above activity. I expressly absolve the City of Gilroy, its officers, employees, agents and servants of liability for their negligence. PARTICIPANT SIGNATURE DATE Are you under 18 years of age? YES NO SIGNATURE OF PARENT OR GUARDIAN (required for participants under the age of 18) PRINT NAME OF PARENT OR GUARDIAN City of Gilroy Liability Release (Aquatics) i vszrAx,a,uxa ACORU® CERTIFICATE OF LIABILITY INSURANCE DATE /Y 06/18/218 /2 013 3 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 0726293 1- 415 -546 -9300 Arthur J. Gallagher 6 Co. Insurance Brokers of California, Inc., License #0726293 CONTACT NAME: PHONE FAX A/C No: ADDRESS: One Market Plaza, Spear Tower Suite Suite 200 X San Francisco, CA 94105 INSURERS AFFORDING COVERAGE NAIC0 _ INSURER A: AMERICAN ALT INS CORP 19720 Loann Le INSURED INSURER 8 South Santa Clara County FPD DAMAGE PREMISES I Ea RENTED ocwrrence INSURER C: INSURER D: 15670 Monterey Street INSURER E: Morgan Hill, CA 95037 MED EXP (Any one person) $ 5,000 INSURER F: COVERAGES CERTIFICATE NUMBER: 34244258 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 ADDL SUBR POLICY NUMBER POLICY MWDD/YYYY LIMITS A GENERAL LIABILITY X VFIS -TR- 0022468 -10 07/01/1 07/01/14 EACH OCCURRENCE $ 1,000,000 X COMMERCIAL GENERAL LIABILITY DAMAGE PREMISES I Ea RENTED ocwrrence $ 1,000,000 CLAIMS -MADE � OCCUR MED EXP (Any one person) $ 5,000 X $0 SIR PERSONAL B ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2.000,000 GEN'L AGGREGATE LIMIT APPLIES PER PRODUCTS - COMP /OP AGG $2,000,000 $ JECT X POLICY PRO- LOC AUTOMOBILE LIABILITY BINED ent CEa i OM SINGLE LIMIT BODILY INJURY (Per person) $ ANY AUTO ALL OWNED SCHEDULED AUTOS AUTOS BODILY INJURY (Per accident) $ PROPERTY DAMAGE Per accident $ NON -OWNED HIRED AUTOS AUTOS $ UMBRELLA LIAB HCLAIMS-MADE OCCUR EACH OCCURRENCE $ AGGREGATE $ EXCESS LIAR DED I RETENTION E $ WORKERS COMPENSATION WC STATU- I OTH- AND EMPLOYERS' LIABILITY YIN ANY PROPRIETOR/PARTNER/EXECUTIVE E.L. EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? ❑ NIA E.L. DISEASE - EA EMPLOYE L$ (Mandatory In NH) If yes, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE -POLICY LIMIT 1 $ DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required) City of Gilroy, its Officers, Officials and Employees are also named as Additional Insureds as respects the shared of Battalion Chief Agreement. CERTIFICATE HOLDER CANCELLATION ACORD 25 (2010105) sandysan 34244258 ©1988 -2010 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD N 4+. O N m N Z W SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE City of Gilroy THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. 7351 Rosanna Street AUTHORIZED REPRESENTATIVE Gilroy, CA 95020dr�. USA �J ACORD 25 (2010105) sandysan 34244258 ©1988 -2010 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD N 4+. O N m N Z W Pi21,0I28002 Policy Number: VFIS -TR- 0022458 -10 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - DESIGNATED PERSON OR ORGANIZATION This endorsement modifies insurance provided under the following: GENERAL LIABILITY COVERAGE PART Name of person or organization: City of Gilroy, its Officers, Officials and Employees 7351 Rosanna Street Gilroy, CA 95020 [If no entry appears above, the information required to complete this endorsement will be shown in the Declarations as applicable to this endorsement.] SECTION II. WHO IS AN INSURED is amended to include as an insured the person or organization shown above, but only with respect to liability arising out of your operations or premises owned by or rented to you. VGL300 (03103) Copyright 2002 American Alternative Insurance Corporation. All Page 1 of 1 rights reserved. Includes copyrighted material of the Insurance GENERAL LIABILITY Services Office, Inc with its permission. N w Q N M N N r_ z w °' CERTIFICATE OF LIABILITY OI ° °' "4 INSURANCE 04 /22 /zz /zo13 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 0726293 1- 415 -546 -9300 CONTACT Arthur Gallagher & Co. Insurance ce Brokers of California, Inc., License #0726293 One Market Plaza, Spear Tower Suite 200 NAME: PHONE FA IAIC No ExH' AIC No: E -MAIL - ADDRESS: INSURERS AFFORDING COVERAGE NAIL# San Francisco, CA 94105 INSURER A: AMERICAN ALT INS CORP 19720 Loan. Le INSURED South Santa Clara County PPD INSURER B: COMMERCIAL GENERAL LIABILITY x] COMMERCIAL INSURER C 15670 Monterey Street INSURER D: 81,000,000 INSURER E: g 5,000 Morgan Hill, CA 95037 . INSURER F : GUVEKAGES CERTIFICATE NUMBER: 33192188 RF\ /IClnkl MI Ikncco. 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 ADDL INSR SUBR WVD POLICY NUMBER POLICY EFF MMIDDIYYYV POLICY EXP MM /DDIYYYY LIMITS A GENERAL LIABILITY X VPIS -TR- 0022468 -9 07/01/1 07/01/13 EACH OCCURRENCE $ 1,000,000 COMMERCIAL GENERAL LIABILITY x] COMMERCIAL TO RENTED PREMISES Ea occurrence) 81,000,000 MED EXP (Any one person) g 5,000 CLAIMS MADE L J OCCUR X $0 SIR PERSONAL &ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GENT AGGREGATE LIMIT APPLIES PER PRODUCTS - COMP /OP AGO $ 2,000,000 X POLICY PEA LOG $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea accident $ BODILY INJURY (Per person) $ ANY AUTO ALL OWNED SCHEDULED AUTOS AUTOS BODILY INJURY (Per accident) $ HIRED AUTOS NON -OWNED AUTOS PROPERTY DAMAGE {Per accidentl $ UMBRELLA LIAR OCCUR EACH OCCURRENCE $ AGGREGATE $ EXCESS LIAB CLAIMS -MADE DIED RETENTION $ $ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY YIN WC STATU- OTH- T R IMITS ER E.L. EACH ACCIDENT $ ANY PROPRIETOR/PARTNER/EXECUTIVE D OFFICER /MEMBER EXCLUDED? N E.L. DISEASE - EA EMPLOYEE $ (Mandatory in NH) If yes, describe under E.L. DISEASE -POLICY LIMIT $ DESCRIPTION OF OPERATIONS below DESCRIPTION OF OPERATIONS/ LOCATIONS I VEHICLES (Attach ADDED 101, Additional Remarks Schedule, if more space is required) City of Gilroy, its Officers, Officials and Employees are also named as Additional Insureds as respects the shared of Battalion Chief Agreement. CERTIFICATE HOLDER CANCELLATION City of Gilroy SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. 7351 Rosanna Street AUTHORIZED REPRESENTATIVE Gilroy, CA 95020 USA ppr,q t1 {0 ACORD 25 (2010105) loannle © 1988 -2010 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD Policy Number: VFIS -TR- 0022468 -9 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - DESIGNATED PERSON OR ORGANIZATION This endorsement modifies insurance provided under the following: GENERAL LIABILITY COVERAGE PART Name of person or organization: City of Gilroy, its Officers, officials and Employees 7351 Rosanna Street Gilroy, CA 95020 [If no entry appears above, the information required to complete this endorsement will be shown in the Declarations as applicable to this endorsement.] SECTION II. WHO IS AN INSURED is amended to include as an insured the person or organization shown above, but only with respect to liability arising out of your operations or premises owned by or rented to you. VGL300 (03103) Copyright 2002 American Alternative Insurance Corporation. All Page 1 of 1 rights reserved. Includes copyrighted material of the Insurance GENERAL LIABILITY Services Office, Inc. with its permission. Psarmakuux '�� CERTIFICATE OF LIABILITY INSURANCE DATE 4/22 /DDn13 oa /za /2013 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 !San ADDITIONAL INSURED, the pollcy(les) must be endorsed- It 5UBROGA IIUN 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 0726293 1- 415 -546 -9300 CONTACT Arthur S. Gallagher & Co. PHONE - Insurance brokers Brokers of California, Inc., License #0726293 (A/C. No, Egg IAIC, No): One Market Plaza, Spear Tower E -MAIL ADDRESS: Suite 200 -� - -- - San Francisco, CA 94105 INSURER(S) AFFORDING COVERAGE NAIC9 Loans Le INSURERA: AMERICAN ALT INS CORP 19720 INSURED INSURERS: South Santa Clara County FPD _ INSURER C 15670 Monterey Street INSURER D: Morgan Hill, CA 95037 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: 33191914 REVISION NUMBER: THIS IS '10 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 ADDL SUBR - - -- POLICY EFF POLICY EXP TYPE OF INSURANCE LIMITS LTft POLICY NUMBER MMIDOIYrvY MMIODNYYY A GENERAL LIABILITY X WIS -TR- 0022468 -9 07/01/1 07/01/13 EACH OCCURRENCE $ 1,000,000 % COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED PREMISES( o ante) $ 1 000,000 CLAIMS -MADE X OCCUR I MED EXP (Any o p rson) $ 5,000 X $0 SIR PERSONAL B ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS COMP /OP AGO $ 2,000,000 X POLICY PRO- j LOG 1 $ AUTOMOBILE LIABILITY � CLOMBINED SINGLE LIMIT p accitlenN ANYAUTO BODILY INJURY (Per person) $ ALL OWNE ISCHEDULED BODILY INJURY (Per accitlen0 $ AUTOS _ AUTOS - - NON-OWNED PROPERTY DAMAGE $ HIREDAUTOS AUTOS L(Per accitleng $ UMBRELLA LIAB _ OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS- MA_D_E_ AGGREGATE $ LED I RETENTION$ $ WORKERS COMPENSATION NC STATU- OTH- ANDEMPLOYERS'LIABILITY YIN ,TORY LIMITS.1 ER _.... -.. ANY PROPRIETOWPARTNERIEXECUTIVE E. L. EACH ACCIDENT $ OFFICENMEMBER EXCLUDED? ❑ NIA (Mandator, In NH) DEL. DISEASE -EA EMPLOYE IS $ n yae,tleaetlbe end I -_ TEL. DESCRIPTION OF OPERATIONS below DISEASE POLICY LIMIT $ I DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (AUach ACORD 101, AtltllUOnal Remarks SchaJUlo, N more space Ie refuln,d) City of Gilroy, its Officers, Officials and Employees are also named as Additional Insureds as respects the shared of Battalion Chief Agreement. SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE of Gilroy THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Rosanna Street AUTHORIZED REPRESENTATIVE y, CA 95020 USA ©1988.2010 ACORD CORPORATION. All rights reserved. ACORD 25 (2010105) The ACORD name and logo are registered marks of ACORD Instal. 33191914 Ate- w O N rn °o i ii P52GWW a Policy Number: VF's-TR- 0022468 -9 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY, ADDITIONAL INSURED - DESIGNATED PERSON OR ORGANIZATION This endorsement modifies insurance provided under the following: GENERAL LIABILITY COVERAGE PART Name of person or organization: City of Gilroy, its Officers, Officials and Employees 7351 Rosanna Street Gilroy, CA 95020 [If no entry appears above, the information required to complete this endorsement will be shown in the Declarations as applicable to this endorsement.] SECTION II. WHO IS AN INSURED is amended to include as an insured the person or organization shown above, but only with respect to liability arising out of your operations or premises owned by or rented to you. VGL300 (03/03) Copyright 2002 Amencan Alternative Insurance Corporation. All Page 1 of 1 rights reserved. Includes copyrighted material of the Insurance GENERAL LIABILITY Services Office, Inc. with its permission. w a 0 0 N 0 "> Z w P52.U. Arthur J. Gallagher & Co. One Market Plaza, Spear Tower a Suite 200 San Francisco, CA 94105 Electronic Service Requested 3 -DIGIT 950 5043 0.8502 AT 0.381 luuhldlrliulhlllllllrhll���dlll�ulihlllllhlhlltltltll City o ilroy 35 7351 R0'S' ANNA STREET GILROY, CA 95020 -6141 13 EBIX BPO This document was brought to you by Ebix /CertificatesNow and Arthur J. Gallagher & Co. Insurance Brokers of California, Inc. in San Francisco, CA. - Any documents forwarded with the certificate request were reviewed for the sole purpose of completing the certificate. - If you have questions regarding the content of this document, please contact - the Producer /Agent listed on the certificate of insurance.- The data included in this notice and in the attached document is confidential to - Ebix /CertificatesNow and Arthur J. Gallagher & Co. Insurance Brokers of California, Inc.- This certificate replaces CN Id: 33191914 - cc: The data included in this notice and in the attached document is confidential to Ebix BPO and the party responsible for bringing you this information. Certificate Delivery by CertificatesNow - www.ConfimrNet.com - 877.669.8600 LL 0 M 0 z w Pszruxnxan A� ® CERTIFICATE OF LIABILITY INSURANCE DATE 04/22l0on3 04/22/2013 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 0726293 1- 415 -546 -9300 CONTACT NAME: Arthur Or. Gallagher 6 Co. PHONE IFAX Insurance Brokers of California, Inc., License #0726293 INC. Na, EXO PVC, No) One Market Plaza, Spear Tosser E -MAIL ADDRESS: Suite 200 -_ -_- San Francisco, CA 94105 INSURERIS) AFFORDING COVERAGE NAICe Loam Le INSURER A: AMERICAN ALT INS CORP 19720 INSURED _. _.. _. INSURER B; _. South Santa Clara County FPD INSURER C: 15670 Monterey Street INSURER D.: Morgan Hill, CA 95037 INSURER E: _ INSURER F: COVERAGES CERTIFICATE NUMBER: 33192188 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 SUER POLICYEFF TYPE OF INSURANCE WISH MM/DYEXP LIMITS LTR POLICY NUMBER MMIOOIYYYY � MMIODnYVY A GENERAL LIABILITY IS VFIS-TR- 0022468 -9 07/01/1 07/01/13 EACH OCCURRENCE $ 1,000,000 X. COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED - $ 1,000,000 _ CLAIMS -MADE I.x I OCCUR se) PREMISES (Ea _ an MED EXP (Any one person) $ 5,_000 X $0 SIB I PERSONAL B ADV INJURY $ 1,000,000 1 GENERALAGGREGATE $ 2,000,000 GENT AGGREGATE LIMIT APPLIES PER: COMPIOP ADD $2,000,000 X POLICY PRO LOC j (PRODUCTS $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT LEa agcipenl) ANY AUTO BODILY INJURY (Per person) $ - ALLOWNED SCHEDULED BODILY INJURY (Per accident) -- _ $ AUTOS _ AUTOS NON-OWNED PROPERTY DAMAGE I(Per $ HIREDAUTOS AUTOS acmden0 UMBRELLALIAB OCCUR EACH OCCURRENCE $ _ EXCESS LUIS CLAIMS MADE 'AGGREGATE $ DED RETENTION WORKERS COMPENSATION WCSTATU- OTH- ANDEMPLOYERVLIABILITY YIN TORY LIMIT$ _ ER_. _ ... _.... ANY PROPRIETORIPARTNERIEXECUTIVE❑ E.L. EACH ACCIDENT $ OFFICEWMEMBER EXCLUDED? (MantlataW In NH) N /Ai - - E.L. DISEASE EA EMPLOYE -- $ Il yes, deacnbe under DESCRIPTION OF OPERATIONS below j -- - - - - -- E.L. DISEASE- POLICY LIMIT -- 1 $ II DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ANsh ACORD tot, Addi lonal Remarks Schedule, If more space Is required) City of Gilroy, its Officers, Officials and Employees are also named as Additional Insureds as respects the shared of Battalion Chief Agreement. SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE of Gilroy- THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Rosanna Street AUTHORIZED REPRESENTATIVE y, CA 95020 4s USA n 14RR -1010 ACORn CORPORATION. All A.Ists reserved . ACORD 25 (2010105) The ACORD name and logo are registered marks of ACORD loamle 33192188 w a w O v M O W P52.2.2 Policy Number: ` is -rR- 0022468 -9 — THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. m a 0 ADDITIONAL INSURED - DESIGNATED PERSON OR ORGANIZATION M V O V1 This endorsement modifies insurance provided under the following: W GENERAL LIABILITY COVERAGE PART Name of person or organization: City of Gilroy, its Officers, Officials and Employees 7351 Rosanna Street Gilroy, CA 95020 [If no entry appears above, the information required to complete this endorsement will be shown in the Declarations as applicable to this endorsement.] SECTION II. WHO IS AN INSURED is amended to include as an insured the person or organization shown above, but only with respect to liability arising out of your operations or premises owned by or rented to you. VGL300 (03/03) Copyright 2002 American Alternative Insurance Corporation. All Page 1 of 1 rights reserved. Includes copyrighted material of the Insurance GENERAL LIABILITY services Office, Inc. with its permission.