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HomeMy WebLinkAboutPersonal Impressions - Insurance Certificate (2019)� ® DATE(MMIDD/YYYY) A C" CERTIFICATE OF LIABILITY INSURANCE I 02/07/2019 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 (CONTACT Dawn Scott NAME: RISI, dba Pan American Insurance Services (PAHONo. Extt: (831)233-7383 I FAX No): (877)693-9831 IC NP. O. Box 660 E-MAIL dawn.scott@relationinsurance.com ADDRESS: INSURER(S) AFFORDING COVERAGE NAIC # Salinas CA 93902 INSURERA: Security National INSURED INSURER B : Timothy Kevin Collins I INSURER C : DBA: Personal Impressions I INSURER D : 331 El Cerrito Way I INSURER E : Gilroy CA 95020 I INSURER F : COVERAGES CERTIFICATE NUMBER: 2018 GL 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. TYPE OF INSURANCE POLICY NUMBER LITR NSD SWVD (MMIDDIYYYY) (MMILDD�YY) I LIMITS x COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 x H I DAMAGES 100,000 CLAIMS -MADE OCCUR ( a occurrence) PREMISES (Ea occurrence) $ MED EXP (Any one person) $ 5,000 A Y NA105295006 04/27/2018 04/27/2019 I PERSONAL & ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: I GENERAL AGGREGATE $ 2,000,000 HPRO-❑LOC 1,000,000POLICY OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ (Ea accident) _ ANY AUTO I BODILY INJURY (Per person) $ OWNED SCHEDULED I BODILY INJURY (Per accident) $ AUTOS ONLY AUTOS _ HIRED PROPERTY DAMAGE I $ HNON-OWNED AUTOS ONLY AUTOS ONLY (Per accident) UMBRELLA LIAB OCCUR HCLAIMS-MADE I EACH OCCURRENCE $ EXCESS LIAB I AGGREGATE $ DED I I RETENTION $ $ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y I N I SPER TATUTE I I EORH ANY PROPRIETOR/PARTNER/EXECUTIVE N / A E.L EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? H (Mandatory in NH) E.L. DISEASE - EA EMPLOYEE $ If yes, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT $ DESCRIPTION OF OPERATIONS / LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) RE: All California Operations The City of Gilroy, its officers and employees are additional insured per the attached 49-0108 07 11. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE 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 AUTHORIZED REPRESENTATIVE { / Gilroy CA 95020 / ' i T7- _J I JJJCCC ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY BLANKET ADDITIONAL INSUREDS - OWNERS, LESSEES OR CONTRACTORS This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Policy Number: NA105295006 Named Insured TIMOTHY KEVIN COLLINS PERSONAL IMPRESSIONS Name of Person or Organization: Endorsement Effective: 04/27/18 12:01 a.m. Authorized Representative: SCHEDULE Any person or organization that the named insured is obligated by virtue of a written contract or agreement to provide insurance such as is afforded by this policy. Location: (If no entry appears above, information required to complete this endorsement will be shown in the Declarations as applicable to this endorsement.) A. Section 11—Who Is An Insured is amended to include as an insured the person or organization shown in the Schedule, but only to the extent that the person or organization shown in the Schedule is held liable for your acts or omissions arising out of your ongoing operations performed for that insured. B. With respect to the insurance afforded to these additional insureds, the following exclusion is added: 2. Exclusions 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 site 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. C. The words "you" and "your" refer to the Named Insured shown in the Declarations. D. "Your work" means work or operations performed by you or on your behalf; and materials, parts or equipment furnished in connection with such work or operations. Primary Wordinq If required by written contract or agreement: Such insurance as is afforded by this policy shall be primary insurance, and any insurance or self-insurance maintained by the above additional insured(s) shall be excess of the insurance afforded to the named insured and shall not contribute to it. Waiver of Subroqation If required by written contract or agreement: We waive any right of recovery we may have against an entity that is an additional insured per the terms of this endorsement because of payments we make for injury or damage arising out of "your work" done under a contract with that person or organization. 49-0108 07 11 May Include Copyrighted Material of Insurance Services Offices, Inc. Page 1 of 1 Used with permission POLICYHOLDER COPY NA P.O. BOX 8192, PLEASANTON, CA 94588 CERTIFICATE OF WORKERS' COMPENSATION INSURANCE ISSUE DATE: 11-01-2018 CITY OF GILRY NA 7301 HANNA ST GILROY CA 95020-6129 GROUP: POLICY NUMBER: 9085403-2018 CERTIFICATE ID: 11 CERTIFICATE EXPIRES: 11-01-2019 11-01-2018/11-01-2019 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 10 days advance written notice to the employer. We will also give you 10 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 UNLESS INDICATED OTHERWISE BY ENDORSEMENT, COVERAGE UNDER THIS POLICY EXCLUDES THE FOLLOWING: THOSE NAMED IN THE POLICY DECLARATIONS AS AN INDIVIDUAL EMPLOYER OR A HUSBAND AND WIFE EMPLOYER; EMPLOYEES COVERED ON A COMPREHENSIVE PERSONAL LIABILITY INSURANCE POLICY ALSO AFFORDING CALIFORNIA WORKERS' COMPENSATION BENEFITS; EMPLOYEES EXCLUDED UNDER CALIFORNIA WORKERS' COMPENSATION LAW. EMPLOYER'S LIABILITY LIMIT INCLUDING DEFENSE COSTS: $1,000,000 PER OCCURRENCE. EMPLOYER COLLINS, TIMOTHY K DBA: PERSONAL IMPRESSIONS 331 EL CERRITO WAY GILROY CA 95020 [P1V,NA] ;REV.7-2014) PRINTED : 02-12-2019 IDS Property Casualty Insurance Company 3500 Packerland Drive De Pere, WI 54115-9070 Elizabeth D Collins Timothy Collins 331 El Cerrito Way Gilroy, CA 95020-4432 RENEWAL DECLARATION CALIFORNIA POLICY NUMBER: AI01360117 POLICY PERIOD: 0110512019 - 0710512019 12:01 AM Standard Time LAPSE IN COVERAGE: NONE FOR CLAIMS SERVICE CAL] 1-888-404-5365 FOR CLIENT SERVICE CALI 1-888-404-5365 COVERAGE/LIMIT1 2007 ACUR 13 2005 CHEV ; 7 2008 TYTA MDX AWD ! SLVR HD 250 TUNDRA DOUP BODILY INJURY LIABILITY I $66.00 $69.00 $83.00 $250,000 EACH PERSON $500,000 EACH ACCIDENT r PROPERTY DAMAGE LIABILITY INCL INCL INCL $100,000 EACH ACCIDENT MEDICAL EXPENSE - EXCESS COVERAGE INCL INCL INCL $5,000 EACH PERSON UNINSURED MOTORIST BODILY INJURY $6.00 $7.00 $8.00 $25,000 EACH PERSON $50,000 EACH ACCIDENT UNINSURED MOTORIST PROPERTY DAMAGE INCL $1.00 $1.00 CAR 1-WAIVER OF COLLISION DEDUCTIBLE CAR 3-WAIVER OF COLLISION DEDUCTIBLE CAR 7-WAIVER OF COLLISION DEDUCTIBLE I COLLISION $86.00 $47.00 $99.00 DEDUCTIBLES CAR 1-$250 3-$500 7-$500 COMPREHENSIVE $24.00 $6.00 $28.00 DEDUCTIBLES CAR 1-$250 3-$500 7-$500 TOWING AND LABOR COSTS NONELECT NONELECT NONELECT RENTAL EXPENSE NONELECT NONELECT NONELECT I CONSOLIDATED VEHICLE ASSESSMENT FEE $0.87 $0.87 $0.87 TOTAL SEMIANNUAL PREMIUM PER VEHICLE $182.87 $130.87 $219.87 CONVENIENCE FEE' - $5.00 TOTAL SEMIANNUAL PREMIUM ALL VEHICLES - $538.61 Coverage is provided only when both a premium and limit are shown. Convenience Fee is $4 per monthly installment if payment is made by credit/debit card or $1 per monthly installment for a preauthorized withdrawal method. adca0la(001) 111201201 £ DRIVEL INFORMATION I. Elizabeth D Collins 2. Timothy Collins 3. * QUALIFIES FOR GOOD STUDENT DISCOUNT * QUALIFIES FOR MATURE DRIVER DISCOUNT CAR INFORMMATION 2007 ACUR 2HNYD28487H502233 2005 CHEV IGBHC29U65E228014 200E TYTA 5,TBBV58168S522959 YOUR POLICY HAS THE FOLLOWING DISCOUNTS: MULTI -CAR, PREMIER SAFETY, TENURE, MULTI PRODUCT, COSTCO 2007 ACUR - DUAL AIRBAG. GOOD DRIVER 2005 CHEV - DUAL AIRBAG, GOOD DRIVER 2008 TYTA - DUAL AIRBAG. GOOD DRIVER, ANTI -THEFT DEVICE 4. 5 { 6. I # EXCLUDED DRIVER I { CARS INEPT AT LOCATION OTHER THAN RESIDENCE YOUR POLICY HAS THE FOLLOWING ENDORSENIENTS: SPECIAL EQUIPMENT/CUSTOMIZATION: NONE LIENHOLDER INFORMATION 2005 CHEV SLVR HD 2500 2WD - Hitachi Capital America Corp Minneapolis, NIN cdec09 - CA , — ., BOARD ST AC = �� ~°-^~-- \ND\V DNS PERSONAL ^°.0 3 30 05/3112020 vwwvoslb-oa.gvv --- 2/14/2019 Check A License - License Detail CONTRACTORS STATE LICENSE BOARD Contractor's License Detail for License # 645936 ISCLAIMER: A license status check provides information taken from the CSLB license database. Before relying on this (formation, you should be aware of the following limitations. CSLB complaint disclosure is restricted by law (B&P 7124.6) If this entity is subject to public complaint disclosure, a link for complaint disclosure will appear below. Click on th link or button to obtain complaint and/or legal action information. Per B&P 7071.17 , only construction related civil judgments reported to the CSLB are disclosed. Arbitrations are not listed unless the contractor fails to comply with the terms of the arbitration. Due to workload, there may be relevant information that has not yet been entered onto the Board's license database. This license is current and active. All information below should be reviewed. C33 - PAINTING AND DECORATING Business Information PERSONAL IMPRESSIONS 331 EL CERRITO WAY GILROY, CA 95020 Business Phone Number:(408) 843-7256 Entity Sole Ownership Issue Date 05/23/1992 Expire Date 05/31 /2020 License Status Classifications Bondinq Information Contractor's Bond Data current as of 2/14/2019 10:01:16 Al This license filed a Contractor's Bond with BUSINESS ALLIANCE INSURANCE COMPANY. Bond Number: G61206560312 Bond Amount: $15,000 Effective Date: 12/06/2016 Contractor's Bond History Workers' Compensation This license has workers compensation insurance with the STATE COMPENSATION INSURANCE FUND Policy Number:9085403 Effective Date: 01/10/2014 Expire Date: 11/01/2019 Workers' Compensation History CERTHOLDER COPY NA P.O. BOX 8192, PLEASANTON, CA 94588 CERTIFICATE OF WORKERS' COMPENSATION INSURANCE ISSUE DATE: 11-01-2018 CITY OF GILRY NA 7301 HANNA ST GILROY CA 95020-6129 GROUP: POLICY NUMBER: 9085403-2018 CERTIFICATE ID: 11 CERTIFICATE EXPIRES: 11-01-2019 11-01-2018/11-01-2019 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 10 days advance written notice to the employer. We will also give you 10 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 UNLESS INDICATED OTHERWISE BY ENDORSEMENT, COVERAGE UNDER THIS POLICY EXCLUDES THE FOLLOWING: THOSE NAMED IN THE POLICY DECLARATIONS AS AN INDIVIDUAL EMPLOYER OR A HUSBAND AND WIFE EMPLOYER; EMPLOYEES COVERED ON A COMPREHENSIVE PERSONAL LIABILITY INSURANCE POLICY ALSO AFFORDING CALIFORNIA WORKERS' COMPENSATION BENEFITS; EMPLOYEES EXCLUDED UNDER CALIFORNIA WORKERS' COMPENSATION LAW. EMPLOYER'S LIABILITY LIMIT INCLUDING DEFENSE COSTS: $1,000,000 PER OCCURRENCE. EMPLOYER COLLINS, TIMOTHY K DBA: PERSONAL IMPRESSIONS 331 EL CERRITO WAY GILROY CA 95020 M0408 (REV.7-2014) PRINTED : 10-17-2018 } e tp of Oirxop 7351 Rosanna Street Gilroy, California 95020-6197 Revie}v information.for acctu-acy. If changes are made, returns this fibrin to above address. PERSONAL IMPRESSIONS 331 EL CERRITO WAY GILROY , CA 95020-4432 Business Information 331 EL CERRITO WAY GILROY , CA 95020-4432 (408) 843-7256 Business License Phone (408) 846-0420 Business License Fax (408) 846-0421 Aug 01, 2018 Business ID# 498 License # 489 Category ID CNTR-G Units 1.00 Owner Infonnation COLLINS, TIMOTHY K 'lease detach license at this perf —� and post it in a conspicuous place. Citp of offrop MUNICIPAL LICENSE License Expiration Date 06/30/2019 PERSONAL IMPRESSIONS 331 EL CERRITO WAY GILROY , CA 95020-4432 COLLINS, TIMOTHY K If you have any questions regarding this license, please call (408) 846-0420. in conformity with the ordinance of the City of Gilroy. NOTE: Licenses are due and payable July 1 st and January 1st, unless otherwise provided by Ordinance, Payments received 30 days after expiration date will be subject to a penalty of 25% the first month and an additional penalty of 10% each month thereafter. Issue Date Business ID# - License # Category ID 10/05/1999 498 489 CNTR-G This license is islued without verification that the License is subject to an exemption from licensing by the State. SBA 558. PnSt License in Conspicuous Place. THIS LICENSE IS NOT TRANSFERABLE. 084331