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HomeMy WebLinkAboutGraham Prewett - Insurance Certificate,�c o CERTIFICATE OF LIABILITY INSURANCE FDATE (MM/DD/YYYY) � 01/2018 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 AU Insurance Services 10825 Old Mill Rd NAME: PHONE WC, No, Ext): (877)234 -4420 FAX (A/C, No) : (877) 234 -4421 Omaha, NE 68154 E -MAIL ADDRESS: (877)234 -4420 PRODUCER CUSTOMER ID# INSURER(S) AFFORDING COVERAGE NAIC # $ INSURED INSURER A: California Insurance Co. 38865 INSURER B: MED EXP (any one person) Graham Prewett, Inc. INSURER C: PERSONAL & ADV INJURY 2773 N Business Paris Ave INSURER D: Ste 102 Fresno, CA 93727 -8662 CTL 1273 1420825 INSURER E: PRODUCTS - COMP /OP AGG INSURER F: $ t;OVEKAGEs CERTIFICATE NUMBER: REVISION N11MRFP: 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 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. INSR LTR TYPE OF INSURANCE ADDL INSR SUB WVD POLICY NUMBER POLICY EFF MM /DD/YYW ) POLICYEXP (MMIDDIYYY"l HIVITS GENERAL LIABILITY COMMERCIAL GENERAL LIABILITY CLAIMS MADE ❑ OCCUR F-1 OCCURRENCE $ DA DAMA GETO RENTED MED EXP (any one person) $ PERSONAL & ADV INJURY $ GENERAL AGGREGATE $ GEN'L AGGREGATE LIMIT APPLIES PER: PRO _ POLICY JECT LOC PRODUCTS - COMP /OP AGG $ $ AUTOMOBILE LIABILITY ANYAUTO ALL OWNED AUTOS SCHEDULEDAUTOS HIRED AUTOS NON -OWNED AUTOS ❑ F-1 COMBINED SINGLE LIMIT Ea accident $ BODILY INJURY Per erson $ BODILY INJURY Per accident $ PROPERTY DAMAGE Per accident $ UMBRELLA LIAR EXCESS LIAB OCCUR CLAIMS MADE ❑ ❑ EACH OCCURRENCE S l AGGREGATE $ DEDUCTIBLE RETENTION $ $ A WORKERS COMPENSATION ANDEMPLOYERS'LIABILITY YIN ANY PROPRIETOR/PARTNER/EXECUTIVE N OFFICER/MEMBER EXCLUDED? (Mandatory in NH) If yes, describe under SPECIAL PROVISIONS below N/ A❑ 73-521996-01-03 5 2 1 9 9 6- 0 1- 0 3 02/01/2018 02/01/2019 X WC STATU- OTH- ITORY LIMIT E.L. EACH ACCIDENT $ 1, 000, 0 0 0 E.L. DISEASE - EA EMPLOYEE $ 1, 000, 0 0 0 E.L. DISEASE - POLICY LIMIT $ 1 , 0 0 0 , 0 0 0 DESCRIPTION OF OPERATIONS/ LOCATIONS /VEHICLES (Attach Acord 101,Additional Remarks Schedule, if more space is required) Job; City Hall - City of Gilroy, 7351 Rosanna Street, Gilroy CA 95020 ®Waiver of Subrogation in favor of The City of Gilroy, its officers, officials and employees The blanket waiver applies to all operations for City of Gilroy for whom the named insured has agreed by written contract to furnish this waiver. CE=RTIFICATE HOLDER CANCELLATION City of Gilroy 7351 Rosanna Street Gilroy, CA 95020 ACORD 25 (2009/09) 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 OD78336 n19RR -7009 ArOPr1 rnPPnPATI(1N 011 Ai kft ­­­4 WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 01 03 03 WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT 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, but this waiver applies only with respect to bodily injury arising out of the operations described in the Schedule where you are required by a written contract to obtain this waiver from us. This endorsement shall not operate directly or indirectly to benefit anyone not named in the Schedule. The premium for this endorsement is shown in the Schedule. Schedule 1. () Specific Waiver Name of person or organization: (x) Blanket Waiver Any person or organization for whom the Named Insured has agreed by written contract to furnish this waiver. 2. Operations: 3. Premium 2500 The premium charge for this endorsement shall be of the premium developed on payroll in connection with work performed for the above person(s) or organization(s) arising out of the operations described. 4. Minimum Premium 5. Advance Premium This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated. Endorsement Effective 02/01/18 Policy No. 73- 521996 -01 -03 Endorsement No. 8 Insured Graham Prewett, Inc. Premium $ 2, 500.00 Insurance Company California Insurance Company Countersigned by ACO ® DATE (MM/DDIYYYY) CERTIFICATE OF LIABILITY INSURANCE 6/29/2017 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. NTACT Carrie Stubblefield CISR - NAME James G.Parker Insurance Associates PH - License_ #0554959 P O Box 3947 Fresno CA 93650 0 INSURED Graham Prewett Inc 2773 N Business Park Ave # 102 oNE . (559) 222 -7722. 1 aC No. (559) 222 -1724 -MAIL ADDRESS. CarrieStubblefie �9P ld@ arker.com - - B:HDI Global ter Surrilus Fresno CA 93727 1 INSURER F COVERAGES CERTIFICATE NUMRER-17 -18 GL BA IM POLL EXCS RFVICICIN NI IMRFR• 2385( 22292 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 A L SUBR POLICY NUMBER POLICY EFF MM /DD/YYYY POLICY EXP MM /DDrCM LIMITS A X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE ❑X OCCUR EACH OCCURRENCE 1,000,000 $ DAMAGE T RENTED PREMISES Es occunence $ 100 , 000 MED EXP (Any one person) $ 5,000 X y PPK1676794 7/1/2017 7/1/2018 PERSONAL & ADV INJURY $ 1, 000 , 000 GEN'L AGGREGATE LIMIT APPLIES PER POLICY II PEC LOC GENERAL AGGREGATE , $ 2,000,066 _ t PRODUCTS - COMP /OP AGG $ 2 , 000, 000 Per Project Aggregate Cap $ 10,000,-000 OTHER AUTOMOBILE LIABILITY CE, O aBI EDtSINGLE LIMIT g 1,000,000 X BODILY INJURY (Per person) $ B ANY AUTO _ ALL OWNED SCHEDULED AUTOS AUTOS TBD 7/1/2017 7/1/2018 BODILY INJURY (Per accident) $ X NON -OWNED HIRED AUTOS X AUTOS PROPERTY DAMAGE Per accident $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ 4,000,000 X AGGREGATE $ 4,000,000 A EXCESS LIAB CLAIMS -MADE DED I I RETENTION$ $ PU33590774 7/1/2017 7/1/2018 WORKERS COMPENSATION AND EMPLOYERS' LIABILITY YIN ANY PROPRIETOR/PARTNER /EXECUTIVE OFFICER /MEMBER EXCLUDED? ❑ N/A PER OTH- STATUTE I I ER E L EACH ACCIDENT $ E L DISEASE - EA EMPLOYE $ (Mandatory in NH) If yes, describe under - .�i - E L DISEASE - POLICY LIMIT I $ DESCRIPTION OF OPERATIONS below C Rented /Leased Equipment REFD29656400 7/1/2017 7/1/2018 $ 1,000 Deductible $150,000 D Pollution Liability 646783918001 7/1/2017 7/1/2018 $10,000 Deductible $2,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) Job: City Hall - City of Gilroy, 7351 Rosanna Street, Gilroy CA 95020 The City of Gilroy, its officers, officials and employees are included as Additional Insured and Waiver of Subrogation coverage applies as per forms CG2010 0413, CG2037 0413, CG2001 0413 b CG2404 0509 attached. VC City of Gilroy 7351 Rosanna Street Gilroy, CA 95020 ACORD 25 (2014/01) INS025 /2m401t 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 J Parker III /CARRIE ©1988 -2014 ACORD CORPORATION- All riahts reserved_ The ACORD name and logo are registered marks of ACORD POLICY NUMBER: PPK1676794 COMMERCIAL GENERAL LIABILITY CG 20 10 04 13 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - OWNERS, LESSEES OR CONTRACTORS - SCHEDULED 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) Locations Of Covered Operations CITY OF GILROY, ITS OFFICERS, ALL COVERED LOCATIONS OFFICIALS AND EMPLOYEES 7351 ROSANNA STREET GILROY, CA 95020 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: 1. Your acts or omissions; or 2. The acts or omissions of those acting on your behalf; in the performance of your ongoing operations for the additional insured(s) at the location(s) designated above. 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 additional exclusions apply: This insurance does not apply to "bodily injury" or "property damage" occurring after: 1. All work, including materials, parts or equipment furnished in connection with such work, on the project (other than service, maintenance or repairs) to be performed by or on behalf of the additional insured(s) at the location of the covered operations has been completed; or 2. That portion of 'your work" out of which the injury or damage arises has been put to its intended use by any person or organization other than another contractor or subcontractor engaged in performing operations for a principal as a part of the same project. CG 2010 0413 0 Insurance Services Office, Inc., 2012 Page 1 of 2 C. 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. Page 2 of 2 0 Insurance Services Office, Inc., 2012 CG 2010 0413 POLICY NUMBER: PPK1676794 COMMERCIAL GENERAL LIABILITY CG 20 37 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) Or Organization(s) Location And Description Of Completed Operations CITY OF GILROY, ITS OFFICERS, OFFICIALS AND EMPLOYEES 7351 ROSANNA STREET GILROY CA 95020 ALL COVERED LOCATIONS 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 0 Insurance Services Office, Inc., 2012 Page 1 of 1 Policy #PPK1676794 CONRYERCIAL GENERAL LIABILITY CG 20 010413 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART PRODUCTS/ COMPLETED OPERATIONS LIABILITY COVERAGE PART The following is added to the Other Insurance (2) You have agreed in writing in a contract or Condition and supersedes any provision to the agreement that this insurance would be contrary: primary and would not seek contribution Prfrt y And Noncontributory Insurance from , any other insurance available to the This insurance is primary to and will not seek additional insured. contribution from any other insurance available to an additional insured under your policy provided that: (1) The additional insured is a Named Insured under such other insurance; and ONLY APPLIES TO THE CITY OF GILROY, ITS OFFICERS, OFFICIALS AND EMPLOYEES CG 20 010413 0 Insurance Services Office, -Inc., 2012- Page -y of 1 POLICY NUMBER: PPK1676794 WAIVER OF TRANSFER OF RIGHTS AGAINST OTHERS TO This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART PRODUCTS/ COMPLETED OPERATIONS LIABILITY COVERAGE PART Name Of Person Or Organization: THE STATE OF CALIFORNIA, THE UNIVERSITY, THE UNIVERSITY, REPRESENTATIVES, VOLUNTEERS, SCHEDULE COMMERCIAL GENERAL LIABILITY CG 24 04 05 09 OF RECOVERY us TRUSTEES OF THE CALIFORNIA STATE THEIR OFFICERS, EMPLOYEES, AND AGENTS in the The following is added to Paragraph 8. Transfer Of Rights Of Recovery Against Others To Us of Section IV — Conditions: We waive any right of recovery we may have against the person or organization shown in the Schedule above because of payments we make for injury or damage arising out of your ongoing operations or "your work" done under a contract with that person or organization and included in the "products - completed operations hazard ". This waiver applies only to the person or organization shown in the Schedule above. CG 24 04 05 09 © Insurance Services Office, Inc., 2008 Page 1 of 1 11 A`°R°` CERTIFICATE OF LIABILITY INSURANCE oaE`oaoi� TYPE OF INSURANCE ADDL INSR 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(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 endorsement(s). PRODUCER CONTACT NAME: PHONE (ac, No, E # ): (877) 234 -4420 FAX (A/C. No) (877) 234 -4421 JO Insur8IICe Services 10825 Old Mill Rd E -MAIL rmwhg, = 68154 ADDRESS: PRODUCER MED EXP An one emu (877)234-4420 CUSTOMER ID # INSURER(S) AFFORDING COVERAGE NAIC # INSURED INSURER A: California Ineurance Co. 38865 INSURER B: PRODUCTS - COMP /OP AGG $ Grabna Prewett, ]37c. 2773 N Business Park Ave INSURER C: INSURER D: LIABILITY ANY AUTO ALL OWNED AUTOS SCHEDULED AUTOS HIRED AUTOS NON -OWNED AUTOS Ste 102 INSURER E: Fresno, CA 93727 -8662 CTL 1273 1293547 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 INSR SUBR WVD POLICY NUMBER POLICY EFF MM/DD POLICY EXP MMlDD LIMITS GENERAL LIABILITY COMMERCIAL GENERAL LIABILITY CLAIMS MADE � OCCUR ❑ ❑ EACH OCCURRENCE $ DAMAGE TO RENTED PREMISES (Ea occurrerice) $ MED EXP An one emu $ PERSONAL & ADV INJURY $ GENERALAGGREGATE $ GEN'LAGGREGATE LIMIT APPLIES PER: POLICY PROJECT LOC PRODUCTS - COMP /OP AGG $ Is AUTOMOBILE LIABILITY ANY AUTO ALL OWNED AUTOS SCHEDULED AUTOS HIRED AUTOS NON -OWNED AUTOS ❑ ❑ COMBINED SINGLE LIMIT (Ea accident) $ BODILY INJURY Per ermn $ BODILY INJURY Per accident $ PROPERTY Per DAMAGE $ UMBRELLA LIAB ,EXCESS LIAR OCCUR CLAIMS -MADE ❑ ❑ EACH OCCURRENCE $ AGGREGATE $ DEDUCTIBLE RETENTION $ $ $ y� y� WORKERS COMPENSATION EMPLOYERS' LIABILITY Y / N ANY PROPRIETOR/PARTNER/ � EXECUTIVE OFFICER /MEMBER [ EXCLUDED? (Mandatory In NH) If yyes, describe under SKECIAL PROVISIONS below N/A [X] 73- 521996 -01 -02 02/01/2017 02/01/2018 X WC STATLI OT H- T R IMIT ER 0 E.L. EACH ACCIDENT $ 1,000.000 E.L. DISEASE -EA EMPLOYEE $ 1,,000' 000 E.L. DISEASE - POLICY LIMIT $ 100000000 SCRIIPpTION OF PERtil ONS L LOCATIONS L 1/EHICLES (Attalh Acord 101 Additional Remarks Schedule, if more space Is required) gob. City 1�a14 -City of ray, 7351 Rosanna Crest, Gilroy CB 95090 Waiver of Subrogation in favor of The City of Gilroy, its officers, officials and employees The blanket waiver applies to all operations for City of Gilroy for whom the named insured has City Ol' Gilrw 7351 Rocaationa Street Gilmy, OL 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 OD78336 ACORD 25 (2009/09) The ACORD name end logo are registered marks of ACORD ®1988 -2009 ACORD CORPORATION. All rights reserved. r AcoRa' CERTIFICATE OF LIABILITY INSURANCE lh� 1 DATE (MM/DD/YYYY) 02/03/2017 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 endorsement(s). PRODUCER CONTACT NAME: J0 musurence Services aC,No, Ext): (877)234-4420 FAX No): ( 877) 234 -4421 10825 Old 9111 Rd E -MAIL Oaleba, HE 68154 ADDRESS: PRODUCER DAMAGE TO RENTED PREMISES (Ea omurrence) (877)234-4420 CUSTOMER ID # INSURER(S) AFFORDING COVERAGE NAIC A INSURED INSURER A: California Insurance Co. 38865 G%reban Prowtt, Inc. INSURER B: GEN'L AGGREGATE LIMIT APPLIES PER: POLICY PROJECT LOC dba G rabsm Prewett, Mae. 2773 N BuSine8S Park Ave INSURER C: INSURER D: Ste 102 INSURER E: ❑ Free=, CA, 93727 -8662 CTL 1273 1293630 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 INSR SUER WVD POLICY NUMBER POLICY EFF MM/DD LIMITS GENERAL LIABILITY COMMERCIAL GENERAL LIABILITY CLAIMS MADE F7 OCCUR ❑ ❑ 7PERSONAL EACH OCCURRENCE $ DAMAGE TO RENTED PREMISES (Ea omurrence) $ MED EXP An one person) $ &ADVINJURY $ GENERAL AGGREGATE $ GEN'L AGGREGATE LIMIT APPLIES PER: POLICY PROJECT LOC PRODUCTS - COMP /OPAGG $ AUTOMOBILE LIABILITY ANY AUTO ALL OWNED AUTOS SCHEDULED AUTOS HIRED AUTOS NON -OWNED AUTOS ❑ ❑ COMBINED SINGLE LIMIT (Ea accident) $ BODILY INJURY Per person) $ BODILY INJURY Per accident $ PROPERTY DAMAGE Par accident $ $ $ UMBRELLA LIAR EXCESS LIAB OCCUR CLAIMS -MADE ❑ ❑ EACH OCCURRENCE $ AGGREGATE $ DEDUCTIBLE RETENTION $ $ $ A WORKERS COMPENSATION AND EMPLOYERS' LIABILITY y/ N ANY EXECUTIVE ETOR/PARTNER/ ITT EXECUTIVE OFFICERIMEMBER fL� JI EXCLUDED? (Mandatory in NH) If yes, describe under SPECIAL PROVISIONS below N/A ❑ 73- 521996 -01 -02 02/01/2017 01/2018 WC STATU- OTH- T DRY IMIT R E.L. EACH ACCIDENT $ ' 0�� UUU E.L. DISEASE -EA EMPLOYEE 1,000,000 $ E.L. DISEASE - POLICY Lim r 1,000,000 $ El sc IMft %,qP,%%AWWA0JJTIRff /oYEH1 JAt r t" IR 1 118pAIR r �t�fWA Ri els W911uteers for whom the named insured has agreed by written contract to furnish this waiver. RE: #15 -AS -221 Re- Roofing Project for City / SCRIM Buildings 7351 Roswma St GfUCY, CA 95020 Attn: Project iftmager 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 0.1)78336 ACORD 25 (2009/09) The ACORD name and logo are registered marks of ACORD ©1988.2009 ACORD CORPORATION. Ali rights