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HomeMy WebLinkAboutSourcewise - Insurance CertficateIN REPLY REFER TO: FEBRUARY 26, 2018 CITY OF GILROY 7351 ROSANNA ST GILROY CA 95020 -6141 CERTIFICATE OF WORKERS ----------------------- COMPENSATION INSURANCE ---------------------- CANCELLATION NOTICE ------------- - - - - -- RE: CERTIFICATE DATED JANUARY 1, 2018 THE WORKERS' COMPENSATION INSURANCE POLICY FOR THE EMPLOYER NAMED BELOW WILL BE CANCELLED EFFECTIVE APRIL 3, 2018 AT 12 :01 A.M. IF YOU HAVE ANY QUESTIONS REGARDING THIS NOTICE, PLEASE CONTACT THE EMPLOYER NAMED BELOW EMPLOYER: SOURCEWISE /CAREACCESS SILICON VALLE 2115 THE ALAMEDA SAN JOSE, CA 95126 POLICY 1743601 -18 CUSTOMER SERVICES UNIT SAN FRANCISCO DISTRICT OFFICE (888) 782 -8338 5860 Owens Dr Pleasanton, CA 94588 -3900 Mailing Address: P.O. Box 8192 • Pleasanton, CA 94588 -9682 SCIF 19102 CERTHOLDER COPY P.O. BOX 8192, PLEASANTON, CA 94588 CERTIFICATE OF WORKERS' COMPENSATION INSURANCE ISSUE DATE: 01 -01 -2017 CITY OF GILROY NA 7351 ROSANNA ST GILROY CA 95020 -6141 GROUP: POLICY NUMBER: 1743601 -2017 CERTIFICATE ID: 141 CERTIFICATE EXPIRES: 01 -01 -2018 01 -01- 2017/01 -01 -2018 This is to certify that we have issued a valid Workers' Compensation insurance policy in a form approved by the California Insurance Commissioner to the employer named below for the policy period indicated. This policy is not subject to cancellation by the Fund except upon 30 days advance written notice to the employer. We will also give you 30 days advance notice should this policy be cancelled prior to its normal expiration. This certificate of insurance is not an insurance policy and does not amend, extend or alter the coverage afforded by the policy listed herein. Notwithstanding any requirement, term or condition of any contract or other document with respect to which this certificate of insurance may be issued or to which it may pertain, the insurance afforded by the policy described herein is subject to all the terms, exclusions, and conditions, of such policy. Authorized Representative President and CEO EMPLOYER'S LIABILITY LIMIT INCLUDING DEFENSE COSTS: $1,000,000 PER OCCURRENCE. ENDORSEMENT #0015 ENTITLED ADDITIONAL INSURED EMPLOYER EFFECTIVE 2017 -01 -01 IS ATTACHED TO AND FORMS A PART OF THIS POLICY. NAME OF ADDITIONAL INSURED: CITY OF GILROY ENDORSEMENT #2065 ENTITLED CERTIFICATE HOLDERS' NOTICE EFFECTIVE 07 -01 -2003 IS ATTACHED TO AND FORMS A PART OF THIS POLICY. EMPLOYER SOURCEWISE /CAREACCESS SILICON VALLEY (A NA NON- PROFIT CORP.) 2115 THE ALAMEDA SAN JOSE CA 95126 M0408 IREV.7 -20141 PRINTED 12 -16 -2016 NA 5UUKG -3 OP ID: SO '44c, ®A ®" llkft ' CERTIFICATE OF LIABILITY INSURANCE DATE (MM /DD/YYYY) 12/27/2016 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 Suhr Risk Services 5300 Stevens Creek Blvd. CONTACT . NAME: Select Accounts Department ac NN ,1:408-510-5440 FA/C No): E-MAIL ADDRESS: San Jose, CA 95129 Select Accounts Department COMMERCIAL GENERAL LIABILITY INSURERS AFFORDING COVERAGE NAIC # INSURER A: Nonprofits Ins. Alliance of CA EACH OCCURRENCE $ 1,000,000. INSURED SOurceWise CareAccess Silicon Valley INSURER 8: Lloyds of London X 201714829NP0 2115 The Alameda INSURER C: INSURER D: $ 500,00 San Jose, CA 95126 INSURER E: $ 20,00 INSURER F: COVERAGES CERTIFICATE NUMBER. REVISION. NUMBER`. THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURE_ D 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. I�TR TYPE OF INSURANCE _ DL UB POLICY. NUMBER . MM% DY/YEYFYFY - MMIDD/1�Y LIMITS A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000. CLAIMS -MADE a OCCUR X 201714829NP0 01/01/2017 01/01/2018 PREMISES Ea occurrence $ 500,00 X MED EXP (Any one person) $ 20,00 Owner /Cont Prot. X See "Other Covg" PERSONAL & ADV INJURY $ 1,000,00 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 3,000,00 POLICY ❑PRO- F—] JECT LOC PRODUCTS - COMP /OP AGG $ 3,000,00 Emp Ben. __ $ INC OTHER: AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea accident g 1,000,00 X BODILY INJURY ,(Par person) $ A ANY AUTO 201714829NPO 01/01/2017 01/01/2018 ALL OWNED SCHEDULED AUTOS AUTOS BODILY INJURY (Per accident) $ NON - OWNED HIRED AUTOS AUTOS PROPERTY DAMAGE 1 Per accident $ $ X UMBRELLALIAB X OCCUR EACH,OCCURRENCE $ 2,000,00_ AGGREGATE $ 2,000,OO A EXCESS LIAB CLAIMS -MADE 201714829UMBNPO 01101/2017 01/01/2018 DED I X I RETENTION $ 10,000 $ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY YIN ANYPROPRIETOR/PARTNER /EXECUTIVE OFFICER /MEMBERS EXCLUDED? ❑ N/A PER- OTH- STATUTE ER E.L. EACH ACCIDENT $ E.L. DISEASE - EA EMPLOYEE $ (Mandatory in NH) If yes, describe under E. L. DISEASE -POLICY LIMIT $ DESCRIPTION OF OPERATIONS below A Social Ser Prof 201714829NPO 0110112017 01/0112018 Occ /agg $1M/$3 B cyber -Incl $1M E &O ESF03221731 11/08/2016 11108/2017 OCC /agg 2,000100 DESCRIPTION OF OPERATIONS /:.LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) The City of Gilroy, its officers and employees are named as additional insured per attached endorsement form CG2026. CERTIFICATE HOLDER CANCELLATION GILR000 SHOULD ANY OFTHE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN City of Gilroy ACCORDANCE WITH THE POLICY PROVISIONS. 7351 Rosanna Street Gilroy, CA 95020 AUTHORIZED REPRESENTATIVE ©1988 -2014 ACORD CORPORATION. All rights reserved. ACORD 25 (2014/01) The ACORD name and logo are registered marks of ACORD POLICY NUMBER: 2017 -14829 COMMERCIAL GENE_ RAL LIABILITY CG 20 26 04 13 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): Any person or organization that you are required to add as an additional insured on this policy, under a written contract or agreement currently in effect, or becoming effective during the term of this policy. The additional insured status will not be afforded with respect to liability arising out of or related to your activities as a real estate manager for that person or organization. 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", "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 04 13 © Insurance Services Office, Inc., 2012 Page 1 of 1