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HomeMy WebLinkAboutBengal Engineering - Insurance CertificateA� Rte® CERTIFICATE OF LIABILITY INSURANCE DAM ( oi2D D 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. IMPORTANT: It the certificate holder is an ADDITIONAL INSURED, the policy(les) must have ADDITIONAL INSURED provisions or be endorsed. N 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 endorsemen s . PRODUCER Tina Jackson Insurance Services, Inc 3834 Pemm PI Santa Barbara, CA 93110 cNAmNTr;r Tina Jackson P"CONE 8059662500 FAX ,. 8055635328 E'aAa Una@tinajacksonins.com INSU S AFFORDING COVERAGE NAIL It INSURER A: International Ins CO Of Hannover E%P INSURED Bengal Engineering, Inc 250 Big Sur Drive Santa Barbara CA 93117 INSURERS: U.S. Specialty Insurance Company X INSURER c: Hanover Insurance Group Y INSURER D: The:Hartford 'IG012002813 -00 NSURER E: INSURER F: E 1,000,000 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 dS SUBJECT TO ALL THE TERMS_ , EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR Jm TYPE OF INSURANCE POUCYNUMBER Pwoofyyyy ,POLICY E%P LIMITS - A X COMMERCIALGENERAL"A UTY Y Y 'IG012002813 -00 08/06/201608062017 EACH OCCURRENCE E 1,000,000 CLAIMS -MADE 7X OCCUR PREMISES Me wwryanool E 300.000 MED EXP (Any we i$ 10,000 PERSONALSAOV INJURY ti .'1,000,000. GEN'L AGGREGATE LIMIT APPLIES PER POLICY El JECT 7 LOC GENERAL AGGREGATE Is 2,000,000 PRODUCTS- COMP /OP AGG E 2.000,000 $ OTHER C AUTOMOBILELIASIUTY AW3A50250500 12/12115 12/12/16 lac M $ 1,000,000 X ANY AUTO BODILY INJURY (Per parson) 'S OWNED SCHEDULED AUTOS ONLY AUTOS HIRED NOWOWNED AUTOS ONLY X AUTOS ONLY - X BODILY INJURY (Per acadent) E PROPERTYDAMAGE Pere [ S E UMBRELLA LIAB OCCUR EACH OCCURRENCE E AGGREGATE E L EXCESS _IAB CLAIMS -MADE DED I I RETENTION E I D WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANYPROPRIETOR/PARTNEREXECUTIVE �!F7 OFFICERIMEMBEREXCLUDED7 (Mandatory In NR) NIA 72WEC9783OH -003 05/15/16 05/15/17 X S A ER E.L. EACH ACCIDENT E 1,000,000 E.L. DISEASE -EA EMPLOYEE S 1,000,000 E.L. DISEASE - POLICY LIMn IE 1,000,000 S yea, deacdbe under DESCRIPTION OF OPERATIONS below B Professional Liability USS1526088 09/17/1 09/17/1 $1;000;000 Per lairs -- Retroactive 9/17/97 $2,000,000 Agg agate DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be initiated If more spew Is required) City of Gilroy, its officials, officers and employees are listed as Additional Insured in respects to general liability. Coverage is, primary and non - contributory. Waiver of subrogation applies. 10th Street Preliminary Bridge Engineering Bridge Preventive Maintenance Program Cohansey Bridge 7351 Rosanna Street Gilroy, CA 95020 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 01988.2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016103) The ACORD name and logo are registered marks of ACORD Twenty Mile Insurance Services, Binder DATE: 08/10/2016 Commercial General Liability (Occurrence) form [ISO 12/071 including products & Completed Operations Deductible: $5,000.00 per ooeurenoe including loss adjustment expenses $1,000,000.00 Occurrence / $2,000,000.00 General Aggregate / $2,000,000.00 Product Aggregate Personal Injury $1,000,000.00 Fire Damage Legal Liability $50,000.00 Medical Payments $5,000.00 TERMS AND CONDITIONS Producer / Broker is responsible for all surplus and fees. You are authorized to instruct your agent that Certificates of Insurance will be accepted subject to the following criteria: The licensed insurance producer is authorized to issue certificates of insurance if this policy is written. The certificate will be an accurate representation of the coverage form. They are not authorized to strike out the "will endeavor" clause. They may not type additional wording of any kind except for explanatory wording in the "description" area of the certificate. Any modification of the ACORD Certificate of Insurance, or the issuance of a non - ACORD Certificate of Insurance is not permitted. Certificates of Insurance do not amend, extend or otherwise after coverage afforded under this policy. The Company does not recognize Certificates of Insurance as endorsements or policy change requests. COVERAGES, EXCLUSIONS AND RESTRICTIONS DESCRIPTION OF FORM: [ X ] Commercial General Liability (Occurrence) Forth (ISO 12/07) including Products / Completed Operations with defense in addition to the limit of liability. [ ] Commercial General Liability (Occurrence) Forth (ISO 12107) including Products / Completed Operations with defense included in the limit of liability. AMENDATORY ENDORSEMENTS: Form A Please see attached Form A ADDITIONAL ENDORSEMENTS: Service of (Suit) Process TMGL 203 1011 Additional'Ins'd- Premises w /primary & noncontributory wording TMGL 172 1011 Additional Ins'd- Comp. Operations- Residentialw /primary & noncontributory TMGL 175 1011 Exclusion- Colorado Operations CG 2134 0187 Page:1 INSURED PHONE: WGRx: Bengal Emgineering Inc 250 Big Sur Ave Goleta, CA 93117 - BINDER# DESCRIPTION OF OPERATION General Liability FROM:08/06/2016' 1 112:01 pm TO: 09/0512016 Ix 12:01 am Poucr # IG012002813 -00 EFFECTPIE: 08/06/2016 OMITS COMPANY' Int. Ins Co. of Hannover EXPIRATION: 08/06/2017 Commercial General Liability (Occurrence) form [ISO 12/071 including products & Completed Operations Deductible: $5,000.00 per ooeurenoe including loss adjustment expenses $1,000,000.00 Occurrence / $2,000,000.00 General Aggregate / $2,000,000.00 Product Aggregate Personal Injury $1,000,000.00 Fire Damage Legal Liability $50,000.00 Medical Payments $5,000.00 TERMS AND CONDITIONS Producer / Broker is responsible for all surplus and fees. You are authorized to instruct your agent that Certificates of Insurance will be accepted subject to the following criteria: The licensed insurance producer is authorized to issue certificates of insurance if this policy is written. The certificate will be an accurate representation of the coverage form. They are not authorized to strike out the "will endeavor" clause. They may not type additional wording of any kind except for explanatory wording in the "description" area of the certificate. Any modification of the ACORD Certificate of Insurance, or the issuance of a non - ACORD Certificate of Insurance is not permitted. Certificates of Insurance do not amend, extend or otherwise after coverage afforded under this policy. The Company does not recognize Certificates of Insurance as endorsements or policy change requests. COVERAGES, EXCLUSIONS AND RESTRICTIONS DESCRIPTION OF FORM: [ X ] Commercial General Liability (Occurrence) Forth (ISO 12/07) including Products / Completed Operations with defense in addition to the limit of liability. [ ] Commercial General Liability (Occurrence) Forth (ISO 12107) including Products / Completed Operations with defense included in the limit of liability. AMENDATORY ENDORSEMENTS: Form A Please see attached Form A ADDITIONAL ENDORSEMENTS: Service of (Suit) Process TMGL 203 1011 Additional'Ins'd- Premises w /primary & noncontributory wording TMGL 172 1011 Additional Ins'd- Comp. Operations- Residentialw /primary & noncontributory TMGL 175 1011 Exclusion- Colorado Operations CG 2134 0187 Page:1 Twenty Mile Insurance Services, Waiver of Transfer of Right Deductible Endorsement Exclude your work involving bridges, canals Exclude - construction mgrs E &O, exclude Arch & Eng E &O 1 MM in prof E &O limits required NOTICE Binder DATE: 0811012016 INSURED I PHONE: WORK Bengali Emgineering Inc 250 Big Sur Ave Goleta, CA 93117- CG 2404 1093 CG 0300 0196 Please see attached Rancho Pacific Invoice "Minimum Earned: 250/6 of Premium + Fully Earned Fees** NO Flat Cancellations. !$26 for a return check. SUMMARY DISCLOSURE PREMIUM 7,50000 Our authorization or binder is based on the forms and endorsements indicated and does not attempt to comply with the specifications shown or implicated on the application. Please review the above terms and conditions carefully as they may not provide coverages or terms you requested. Page:2 ACORO0 CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DD/YYYY) 06/08/2016 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 CONTACT NAME: Tina Jackson Tina Jackson Insurance Services, Inc PHONE 8059662500 AX No: 8055635328 No. Ext)w 3834 Pemm PI E -MAIL ADDRESS: tina tina acksonins.com INSURERS AFFORDING COVERAGE NAIC # Santa Barbara, CA 93110 INSURERA: Mesa Underwriters Insurance Company 08/06/2016 EACH OCCURRENCE INSURED INSURER B: U.S. Specialty Insurance Company DAMAGE T RENT -ED PR occurrence) EMISES Ea occurre Bengal Engineering, Inc INSURER C: Hanover Insurance Group MED EXP (Any one person) INSURER D: The Hartford 250 Big Sur Drive Santa Barbara CA 93117 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 ADDL SUBR POLICY NUMBER POLICY EFF MM /DD/YYYY POLICY EXP MM/DD/YYW LIMITS A X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE FX OCCUR Y Y MP0004008007195 08/06/2015 08/06/2016 EACH OCCURRENCE $ 1,000,000 DAMAGE T RENT -ED PR occurrence) EMISES Ea occurre $ 300,000 MED EXP (Any one person) $ 10,000 PERSONAL & ADV INJURY $ 1,000,000 GENL AGGREGATE LIMIT APPLIES PER: POLICY E] PRO- F-1 JECT LOC GENERAL AGGREGATE $ 2,000,000 PRODUCTS - COMP /OPAGG $ 2,000,000 $ OTHER: C AUTOMOBILE LIABILITY AW3A50250500 12/12/15 12/12/16 COMBINED SINGLE LIMIT Ea accident $ 1,000,000 X BODILY INJURY (Per person) $ ANY AUTO ALL OWNED SCHEDULED AUTOS AUTOS P INJURY BODILY INJUer accident ( ) $ X HIRED AUTOS X NON -OWNED AUTOS PROPERTY DAMAGE Per acci en $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ AGGREGATE $ EXCESS LIAB CLAIMS -MADE DIED RETENTION $ $ D WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y / N ANY PROPRIETOR/PARTNER/EX- TIVE OFFICER/MEMBER EXCLUDED? ❑ (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below N / A 72WEC9783OH -003 05/15/16 05/15/17 PER X I STATUTE I ERH E.L. EACH ACCIDENT $ 1,000,000 E.L. DISEASE - EA EMPLOYEE $ 1,000,000 E.L. DISEASE - POLICY LIMIT $ 1,000,000 B Professional Liability USS1526088 9/17/1509/17/16 $1,000,000 Per Claim Retroactive 9/17/97 $2,000,000 Aggregate DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space Is required) City of Gilroy, its officials, officers and employees are listed as Additional Insured in respects to general liability. Coverage is primary and non - contributory. Waiver of subrogation applies. City of Gilroy 7351 Rosanna Street Gilroy, CA 95020 L,ANI;tLLA 1 IUN 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 ©1988 -2014 ACORD CORPORATION. All rights reserved. ACORD 25 (2014/01) The ACORD name and logo are registered marks of ACORD �® CERTIFICATE OF LIABILITY INSURANCE DATE 02 /23/201 YID 02/23/2016 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFIGATEHOLDER. 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 Tina Jackson Insurance Services, Inc NAME: AME: Tina Jackson PHONE 8059662500 N.1:8055635328 E-MAIL tina @tinajacksonins.com ADDRESS: 3834 Pemm PI INSURERS AFFORDING COVERAGE NAIC # Santa Barbara, CA 93110 INSURER A: Mesa Underwriters Insurance Company MP0004008007195 08/06/2015 INSURED INSURER B: U.S. Specialty Insurance Company $ $ 1,000,000 Bengal Engineering, Inc INSURER C: Hanover Insurance Group INSURER D: The Hartford INSURER E: 250 Big Sur Drive Santa Barbara CA 93117 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 ADDL UBR POLICY NUMBER. POLICY EFF MMIOD - , POLICY EXP MMIDDN.YYY LIMITS A X COMMERCIAL GENERAL LIABILITY Y Y MP0004008007195 08/06/2015 08/06/2016 $ $ 1,000,000 CLAIMS -MADE '❑X OCCUR PREMISES Ea occurrence) $ 300,000 MED EXP (Any one person) $ 10,000 PERSONAL & ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 POLICY ❑ JE OT F] LOC PRODUCTS - COMP /OP AGG $ 2,000,000 $ OTHER: C AUTOMOBILE LIABILITY AW3A50250500 12/12/15 12/12/16 COMBINED INGLE LIMIT Ea accident) $ 1,000,000 BODILY INJURY (Per person) $ X ANY AUTO BODILY INJURY (Per accident) :. $ ALL OWNED AUTOS AUTOS X HIRED AUTOS k,SCHEDULED NON -OWNED AUTOS PROPERTY DAMAGE - Per accident $ $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ AGGREGATE $ EX LIAB CLAIMS -MADE DED I I RETENTION $ $ D WORKERS COMPENSATION AND EMPLOYERS LIABILITY ANY PROPRIETOR/PARTNERIEXECUTIVE YIN OFFICER/MEMBER EXCLUDED? (Mandatory in NH) NIA 72WEC9783OH -003 05/15/15 1 05/15/16 x PER ERH AND E.L. EACH ACCIDENT $ 1,000,000 E.L. DISEASE - EA EMPLOYEE $ 1,000,000 tF yyeess, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE - .POLICY LIMIT Fs -1,000,000 B Professional Liability USS1526088 09/17/1509/17/16 $1,000,000 Per Claim Retroactive 9/17/97 $2,000,000 Aggregate DESCRIPTION OF OPERATIONS I LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached If more space Is required) City of Gilroy, its officials, officers and employees are listed as Additional Insured in respects to general liability. Coverage is primary and non- contributory. Waiver of subrogation applies. City of Gilroy 7351 Rosanna Street Gilroy, CA 95020 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 (N ©1988 -2014 ACORD CORPORATION. All rights reserved. ACORD 25 (2014101) The ACORD name and logo are registered marks of ACORD POLICY NUMBER: MP0004008007195 COMMERCIAL GENERAL LIABILITY CG 2037 0413 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - OWNERS, LESSEES OR CONTRACTORS - COMPLETED OPERATIONS This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART PRODUCTS /COMPLETED OPERATIONS LIABILITY COVERAGE PART SCHEDULE Name Of Additional Insured Person(s) Location And Description Of Completed Operations Or Or anization s City of Gilroy, its officers, elected and appointed employees and agents _ 7351 Rosanna St Gilroy, CA 95020 THIS INSURANCE SHALL BE PRIMARY AND NON - CONTRIBUTORY, BUT ONLY IN THE EVENT OF A NAMED INSURED'S SOLE NEGLIGENCE. Information required to complete this Schedule, if not shown above, will be shown in the Declarations. 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" or "property damage" caused, in whole or in part, by "your work" at the location designated and described in the Schedule of this endorsement performed for that additional insured and included in the "products - completed operations hazard ". 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 37 0413 C Insurance Services Office, Inc., 2012 Page 1 of 1 INSURED