Loading...
HomeMy WebLinkAboutPound 4 Pound Boxing - Insurance Certificate (2019)ACC ® CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) I 06/19/2019 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 Darlene Sotelo NAME: Dicar Insurance Marketing WCo. EXt): (408) 848-9085 � ONE A//c, No): (408) 848-5125 6976 Automall Parkway ADDRESS: dicarinsurancel@gmail.com INSURER(S) AFFORDING COVERAGE NAIC # Gilroy CA 95020 INSURER A: Burlington Insurance Company 23620 INSURED INSURER B : Infinity Select Insurance CO. 20260 Ruben Guerrero INSURER C : Burlington Insurance Company 23620 dba Pound 4 Pound Sports Fitness INSURER D : State Compensation Insurance Fund 35076 7648 Monterey St INSURER E : Burlington Insurance Company 26320 Gilroy CA 95020 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 TYPE OF INSURANCE ADDL SUBR POLICY EFF POLICY EXP LIMITS LTR INSD WVD POLICY NUMBER (MM/DD/YYYYI (MM/DD/YYYY) X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 DAMAGE TO RENTED CLAIMS -MADE FX OCCUR I PREMISES Ea occurrence) $ 100,000 I MED EXP (Any one person) $ 5,000 _ A X 904B001670 09/05/2018 09/05/2019 PERSONAL & ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: I GENERAL AGGREGATE $ 2,000,000 POLICY PRO- ❑ LOC JECT I PRODUCTS -COMP/OP AGG $ 1,000,000 OTHER: I Abuse Molestation Liat $ 1,000,000 AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT I (Ea accident) $ 1,000,000 _ ANY AUTO I BODILY INJURY (Per person) $ B OWNED ^ SCHEDULED AUTOS ONLY AUTOS 504-61012-3388-001 06/19/2019 06/19/2020 I BODILY INJURY (Per accident) $ HIRED NON -OWNED PROPERTY DAMAGE $ _ AUTOS ONLY AUTOS ONLY (Per accident) $ X UMBRELLA LIAR X I OCCUR EACH OCCURRENCE $ 1,000,000 C EXCESS LIAB CLAIMS -MADE 904B001670 09/05/2018 09/05/2019 AGGREGATE $ 1,000,000 DED I x I RETENTION $ $ WORKERS COMPENSATION �/ /� I STATUTE I I OERH AND EMPLOYERS' LIABILITY N ANY PROPRIETOR/PARTNER/EXECUTIVE YIN I E.L. EACH ACCIDENT $ 1,000,000 D OFFICER/MEMBER EXCLUDED? YI N / A 801442114 06/19/2019 06/19/2020 (Mandatory in NH) E.L. DISEASE - EA EMPLOYEE $ 1,000,000 If yes, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT $ 1,000 ,000 Errors & Omissions E 904B001670 09/05/2018 09/05/2019 Per Occurence $1,000,000 DESCRIPTION OF OPERATIONS / LOCATIONS I VEHICLES (ACORD 101, Additional Remarks &;hedule, may be attached if more space is required) RE: Proof of Coverage City of Gilroy, It's Officers, Representatives, Agents and Employees are named as additional insured per attached endorsement form CG2026. CERTIFICATE HOLDER CANCELLATION City of Gilroy SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Att: Sandra Cruz 7351 Rosanna Street AUTHORIZED REPRESENTATIVE Gilroy CA 95020-6197 @ 1988.2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016103) The ACORD name and logo are registered marks of ACORD POLICY NUMBER: 904B001670 COMMERCIAL GENERALOBI LIABILITY 3 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): THE CITY OF GILROY, ITS OFFICERS, REPRESENTATIVES, AGENTS, AND EMPLOYEES 7251 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 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 0413 © Insurance Services Office, Inc., 2012 Page 1 of 1 POLICY NUMBER: 904B001670 ENDORSEMENT 9: 5 NAMED INSURED: Mad Dog Guerrero Boxing LLC DBA Pound 4 Pound Sports Fitness INSURANCE COMPANY: The Burlington Insurance Company EFFECTIVE DATE: 04/11/2019 PRODUCER: AmWINS Access Insurance Services, LLC 18630 Sutter Blvd. Morgan Hill CA 95037 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. GENERAL CHANGE ENDORSEMENT This endorsement modifies insurance provided under the following: PACKAGE FOR NO CHANGE IN PREMIUM, IT IS HEREBY AGREED THAT THE FOLLOWING CHANGE HAS BEEN MADE TO THE POLICY: ADD FORM CG2026 0413 ADDITIONAL INSURED - DESIGNATED PERSON OR ORGANIZATION IN FAVOR OF BELOW ENTITY: THE CITY OF GILROY, ITS OFFICERS, REPRESENTATIVES, AGENTS, AND EMPLOYEES 7251 ROSANNA STREET GILROY, CA 95020 Premium for this Change Endorsement: $ 0.00 Additional Premium $. Other Charges, if applicable (specify) $ Other Charges, if applicable (specify) $ Other Charges, if applicable (specify) $ Other Charges, if applicable (specify) $ Other Charges, if applicable (specify) $ Othe harges, if ap able (speciL ?_ $ 0.00 Tot ALL OTHER TERMS AND CONDITIONS OF THIS POLICY REMAIN UNCHANGED. IFG-I-0151 01 05 1 of 1 Issue Date: 07/23/2019