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HomeMy WebLinkAboutSourcewise - Release of LiabilityCITY OF GILROY Telephone FAX: (408) 846 -0 65 hftp:/twww.ci._qilroy.ca.us 7351 Rosanna Street GILROY, CALIFORNIA 95020 Release of Liability for Provision of Services at the Gilroy Senior Center This general waiver and release of liability acknowledges that SOURCEWISE, a 501(c)(3) public benefit corporation, intends to provide a variety of case management and consumer resource services (the "Services ") to individuals at the Gilroy Senior Center, located at 7371 Hanna Street, Gilroy, CA. The Services include, but are not limited to, meeting with seniors at the Gilroy Senior Center, providing referrals to seniors, assisting seniors with completing forms or applications, and providing transportation services to seniors. Prior to provision of Services, the CITY OF GILORY ( "CITY") requires SOURCEWISE to agree to and sign this general waiver and release of liability. By signing this general waiver and release of liability, to the fullest extent permitted by law, SOURCEWISE agrees to defend, through counsel approved by the CITY (which approval shall not be unreasonably withheld), indemnify and hold harmless CITY, its officers, representatives, agents and employees against any and all suits, damages, costs, fees, claims, demands, causes of action, losses, liabilities and expenses, including without limitation attorneys' fees, to the extent arising or resulting directly or indirectly from any willful or negligent acts, errors or omissions of SOURCEWISE or SOURCEWISE's assistants, employees or agents, including all claims relating to the injury or death of any person or damage to any property, arising from or connected with the services provided by SOURCEWISE at the Gilroy Senior Center. In addition, SOURCEWISE shall, at no cost to CITY, obtain and maintain throughout the period in which SOURCEWISE provides Services at the Gilroy Senior Center, Commercial Liability Insurance on a per occurrence basis, including coverage for owned and non -owned automobiles, with a minimum combined single limit coverage of $1,000,000 per occurrence for all damages due to bodily injury, sickness or disease, or death to any person, and damage to property, including the loss of use thereof. SOURCEWISE shall furnish written evidence of such coverage (naming CITY, its officers and employees as additional insureds on the Comprehensive Liability insurance policy referred to immediately above via an insurance certificate and specific endorsement) and requiring thirty (30) days written notice of policy lapse or cancellation, or of a material change in policy terms. SOURCEWISE agrees to provide proof workers' compensation insurance for SOURCEWISE'S employees and agents and agrees to hold harmless, defend with counsel acceptable to CITY and indemnify CITY, its officers, representatives, agents and employees from and against any and all claims, suits, damages, costs, fees, demands, causes of action, losses, liabilities and expenses, including without limitation attorneys' fees, arising out of any injury, disability, or death of any of SOURCEWISE'S employees. By signing below, you certify that you have the authority to agree to the above terms on behalf of SOURCEWISE and do thereb* -tea to the above terms on behalf of SOURCEWISE. Date: i Z -2_6 -I a; fA k Z44-K, Job Title:. (Print Name) 4831- 1603 -84610 MBRANSONV04706083 SOURC -3 OP ID: SO 14CORV° CERTIFICATE OF LIABILITY INSURANCE �-f DATE 127 /2016 ) 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 PHONN Ext : 408- 510 -5440 C No): San Jose, CA 95129 Select Accounts. Department EMAIL ADDRESS: X COMMERCIAL GENERAL LIABILITY INSURERS AFFORDING COVERAGE NAIC # INSURER A: Nonprofits Ins. Alliance of CA EACH OCCURRENCE INSURED SOUrceWlse CareAccess Silicon Valley INSURER B: Lloyds of London CLAIMS -MADE a OCCUR X 2115 The Alameda INSURER C 01101/2018 INSURER 0: PREMISES Ea a occurrence) San Jose, CA 85126 INSURER E: MED EXP (Any one person) $ 20,000 INSURER F: Owner /Cont Prot. 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 RE_ DUCED BY PAID CLAIMS. INSR LTR TYPE OF INSURANCE ADDL SUB POLICY NUMBER POLICY EFF MM /DD/YYYY POLICY EXP MM /DD/YYYY LIMITS A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,00 CLAIMS -MADE a OCCUR X 201714829NPO 01/01/2017 01101/2018 PREMISES Ea a occurrence) $ 500,00 X MED EXP (Any one person) $ 20,000 Owner /Cont Prot. X See "Other Covg" PERSONAL 8 ADV INJURY $ 11000,00 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 3,000,00 POLICY E PRO ❑ LOC JEGT 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 (Per person) $ A ANY AUTO 201714829NPO 01/01/2017 01/01/2018 ALL OWNED SCHEDULED ALTOS AUTOS BODILY INJURY (Per accident) $ HIRED AUTOS NON -OWNED AUTOS PROPERTY DAMAGE Per accident $ $ X UMBRELLA LIAS X OCCUR EACH OCCURRENCE $ 2,000,00 AGGREGATE $ 2,000,00 A EXCESS LIAB CLAIMS -MADE 201714829UMBNPO 01/01/2017 01/01/2018 DED i X I RETENTION $ 10,000 $ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y / N ANY PROPRIETOR /PARTNER /EXECUTIVE OFFICER /MEMBER EXCLUDED? NIA PER TH- STATUTE I I ER E.L. EACH ACCIDENT $ E.L. DISEASE - EA EMPLOYEE $ (Mandatory in NH) If yyes, describe under DESCRIPTION OF OPERATIONS below E. I. DISEASE -POLICY LIMIT $ A Social Ser Prof 201714829NPO 0110112017 01101/2018 occ /agg $1M/$3 B Cyber -Intl $1M Es.O ESF03221731 11/08/2016 11/0812017 occ /agg 2,000,000 DESCRIPTION OF OPERATIONS / LOCATIONS / 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. City of Gilroy 7351 Rosanna Street Gilroy, CA 95020 ACORD 25 (2014/01) GILR000 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. ©1988 -2014 The ACORD name and logo are registered marks of ACORD riahts reserved POLICY NUMBER: 2017 -14829 COMMERCIAL GENERAL 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 If — 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. CO 20 26 04 13 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. © Insurance Services Office, Inc., 2012 Page 1 of 1 POLICYHOLDER COPY NA 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 #6015 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 [P11,NG] (REV.7 -2014) PRINTED : 01 -05 -2017