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Home My WebLink AboutPolychrome Construction - Insurance Certificate (2019)Policy Numbermc5017664 Date Entered.? /17/2018 rn ACORO CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDDrrlYY) `►'� _7/17/2018 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 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 Russell Glatt Insurance Agency 6025 Sepulveda Blvd., Suite 204 Van Nuys, CA 91411 CONTACT NAME: AICNNo Ext: (818)781 -3336 pjXC Ne: (818) 780 -2810 E -MAIL ADDRESS: A X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE OCCUR INSURER(S) AFFORDING COVERAGE NAIC # INSURER A: Benchmark Insurance Company 41394 2/12/2019 INSURED Polychrome Construction, Inc. INSURERS: Farmers Insurance Exchange 155095398 DAMAGE TO RENTED PREMISES Ea occurrence INSURER C: National Union Fire Insurance Co PA 19445 8908 Balboa Blvd INSURERD:Capitol Specialty Insurance Corpora i_gR28 Northridge, CA 91325 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 INSD SUER WVD POLICY NUMBER POLICY EFF MMIDDIYM ) POLICY EXP IMMIDWYYYYI LIMITS A X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE OCCUR $IC5017664 2/12/2018 2/12/2019 EACH OCCURRENCE $1,000,000. DAMAGE TO RENTED PREMISES Ea occurrence $ 50,000. MED EXP (Any one person) $ 5,000. PERSONAL &ADV INJURY $1,000,000. GEN'L AGGREGATE LIMIT APPLIES PER: POLICY ❑ PEA LO GENERAL AGGREGATE $2,000,000. $ 2 r 000, 000. $ OTHER: $ AUTOMOBILE LIABILITY ANYAUTO X 155095398 3/20/2018 9/20/201e COMBINED SINGLE LIMIT Ea..dent $ 1 0 00 0 , , 00. BODILY INJURY (Per person) $ OWNED F SCHEDULED AUTOS ONLY AUTOS I BODILY INJURY (Per accident) $ HIRED NON -OWNED AUTOS ONLY AUTOS ONLY PROPER7YDAMAGE Peracddent $ $ UMBRELLA LIAR HCLAIMS-MADE OCCUR EACH OCCURRENCE $5,000,000. C EXCESS LIAB EBU 013790743 11/23/2017 11/23/2018 AGGREGATE $5,000,000. DED I I RETENTION $ Products /Comp $5,000,000. WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y1 N ANY PROPRIETOR/PARTNERIEXECUTIVE OFFICER/MEMBER EXCLUDED? H NIA PER OTH- STATUTE ER E.L. EACH ACCIDENT $ E.L. DISEASE - EA EMPLOYEE $ (Mandatory In NH) If yes, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT $ D Pollution Liability EV20150570 -02 9/24/17 9/24/18 Aggregate $2,000,000. Per Occurrence $1,000,000. DESCRIPTION OF OPERATIONS I LOCATIONS /VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) RE: Project Description: Fire Hydrant Painting /ID tags project and the Project No. is 18-- RFP -PW -243-2 City of Gilroy, its agents, officers, officials, employees and volunteers are included as Additional Ins in accordance with the policy provisions of the General Liability and Automobile Liability policies. Shou 3eneral Liability, Automobile Liability, Professional Liability and Workers' Compensation policies be =ancelled before the expiration date thereof, the policy, provisions will govern how notice of cancellati : nay be delivered to certificate holders in accordance with the policy provisions. CERTIFICATE HOLDER 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, NOTI, E WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPrSENTHY�� 7"1988 -2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD roduced usina Forms Boss Plus software. www.FormsBoss.com: Impressive Publishina 800 -208 -1977 rec 101 Ou 0071945 -01 THIS ENDORSENIE14T CHANCES THE POLICY. PLEASE REEAAD IT CAREFULLY ADDITIONAL INSURED - OWNERS, LESSEES OR CONTRACTORS - SCHEDULED PERSON O ORGANIZATION This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Name of Additional Insured Person(s) or organization(s) (Additional Insured): Location(s) of Covered Operations: The City of Gilroy its elected and City of Gilroy Project No. 18- RFP -PW- appointed officers, officials, 243 -2 Fire Hydrant Painting /ID tags employees, and volunteers. project. --- . .......... . - - -- — - - - -- -- - - -- -- - - - - -- - _ __ The insurance afforded by this Coverage Part for the additional insured shown in the Schedule is primary insurance and we will not seek contribution from any other insurance available to that additional insured. 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 for whom you are performing operations when you and such person or organization have agreed in writing in a contract or agreement that such person or organization be added as an additional insured on your policy- Such person or organization is an additional insured 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 locations) designated above. A person's or organization's status as an additional insured under this endorsement ends when your operations for that additional insured are completed. B. With respect to the insurance afforded to these additional insureds, the following additional exclusions apply: This insurance does not apply to: Additional Insured Contractual Liability "Bodily injury" or "property damage' for which the additional insured($) are obligated to pay damages by reason of the assumption of liability in a contract or agreement, Finished Operations at Work "Bodily injury„ or "property damage" occurring after: 1. Ail work, including materials, parts or equipment furnished in connection with such wont, 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 workout of which the injury or damage arises has been put to its intended use by any person or organization. Negligence of Additional Insured. U156 -0310 Includes copyrighted material of ISO Properties, Inc., Page 1 of 2 with its permission. *'GI GL 0071945• °Sadily injury" or "property damage" arising directly or indirectly out of the negligence of the additional, insured(s). ALL OTHER TERMS AND CONDITIONS OF THE POLICY REMAIN UNCHANGED, U156 -0310 Includes copyrighted material of ISO Properties, Inc., Page 2 of 2 with its permission. CERTHOLDER COPY P.O. BOX 8192, PLEASANTON, CA 94588 CERTIFICATE OF WORKERS' COMPENSATION INSURANCE ISSUE DATE: 06 -25 -2018 THE CITY OF GILROY SC 7351 ROSANNA ST GILROY CA 95020 -6141 GROUP: POLICY NUMBER: 9099918 -2018 CERTIFICATE ID: 42 CERTIFICATE EXPIRES: 05 -20 -2019 05 -20- 2018/05 -20 -2019 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 #2065 ENTITLED CERTIFICATE HOLDERS' NOTICE EFFECTIVE 05 -20 -2016 IS ATTACHED TO AND FORMS A PART OF THIS POLICY. ENDORSEMENT #2570 ENTITLED WAIVER OF SUBROGATION EFFECTIVE 2018 -06 -25 IS ATTACHED TO AND FORMS A PART OF THIS POLICY. THIRD PARTY NAME: THE CITY OF GILROY ENDORSEMENT #1650 - CONSTANTIN POLYCHRONAS PRESIDENT - EXCLUDED. EMPLOYER POLYCHROME CONSTRUCTION INC. SC 8908 BALBOA BLVD NORTHRIDGE CA 91325 M0408 (REV.7 -2014) PRINTED : 06 -26 -2018 SC IN REPLY REFER TO: OCTOBER 25, 2018 THE CITY OF GILROY 7351 ROSANNA ST GILROY CA 95020-6141 CERTIFICATE OF WORKERS' ----------------------- COMPENSATION INSURANCE ---------------------- CANCELLATION NOTICE ------------------- RE: CERTIFICATE DATED JUNE 25, 2018 THE WORKERS' COMPENSATION INSURANCE POLICY FOR THE EMPLOYER NAMED BELOW WILL BE CANCELLED EFFECTIVE NOVEMBER 30, 2018 AT 12:01 A.M. IF YOU HAVE ANY QUESTIONS REGARDING THIS NOTICE, PLEASE CONTACT THE EMPLOYER NAMED BELOW EMPLOYER: POLYCHROME CONSTRUCTION INC 8908 BALBOA BLVD NORTHRIDGE, CA 91325 POLICY 9099918-18 CUSTOMER SERVICES UNIT LOS ANGELES DISTRICT OFFICE (888) 782-8338 5860 Owens Dr Pleasanton, CA 94588-3900 Mailing Address: P.O. Box 8192 • Pleasanton, CA 94588-9682 SCIF 19102 NOVEMBER 8, 2018 THE CITY OF GILROY 7351 ROSANNA ST GILROY CA 95020-6141 IN REPLY REFER TO: CERTIFICATE OF WORKERS' ----------------------- COMPENSATION INSURANCE ---------------------- CANCELLATION WITHDRAWAL NOTICE ------------------------------ RE: CERTIFICATE DATED JUNE 25, 2018 THE CANCELLATION HAS BEEN WITHDRAWN FOR THE WORKERS' COMPENSATION INSURANCE POLICY FOR THE EMPLOYER NAMED BELOW. THIS LETTER SUPERSEDES THE NOTICE OF CANCELLATION SENT TO YOU ON OCTOBER 25, 2018. THIS EMPLOYER'S WORKERS' COMPENSATION INSURANCE COVERAGE CONTINUED UNINTERRUPTED. REP 05 EMPLOYER: POLYCHROME CONSTRUCTION INC 8908 BALBOA BLVD NORTHRIDGE, CA 91325 POLICY 9099918-18 CUSTOMER SERVICES UNIT LOS ANGELES DISTRICT OFFICE (888) 782-8338 5860 Owens Dr Pleasanton, CA 94588-3900 Mailing Address: P.O. Box 8192 • Pleasanton, CA 94588-9682 SCIF 19102