Loading...
HomeMy WebLinkAboutCOI - Securance, LLC - Expires 2022-02-10DocuSign Envelope ID: 30850883-D9E8-4637-8872-EA867BAD3CC2 The ACORD name and logo are registered marks of ACORD CERTIFICATE HOLDER © 1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25 (2014/01) AUTHORIZED REPRESENTATIVE CANCELLATION DATE (MM/DD/YYYY)CERTIFICATE OF LIABILITY INSURANCE LOCJECTPRO-POLICY GEN'L AGGREGATE LIMIT APPLIES PER: OCCURCLAIMS-MADE COMMERCIAL GENERAL LIABILITY PREMISES (Ea occurrence)$DAMAGE TO RENTED EACH OCCURRENCE $ MED EXP (Any one person) $ PERSONAL & ADV INJURY $ GENERAL AGGREGATE $ PRODUCTS - COMP/OP AGG $ $RETENTIONDED CLAIMS-MADE OCCUR $ AGGREGATE $ EACH OCCURRENCE $ UMBRELLA LIAB EXCESS LIAB DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) INSRLTR TYPE OF INSURANCE POLICY NUMBER POLICY EFF(MM/DD/YYYY)POLICY EXP(MM/DD/YYYY)LIMITS PERSTATUTE OTH-ER E.L. EACH ACCIDENT E.L. DISEASE - EA EMPLOYEE E.L. DISEASE - POLICY LIMIT $ $ $ ANY PROPRIETOR/PARTNER/EXECUTIVE If yes, describe under DESCRIPTION OF OPERATIONS below (Mandatory in NH) OFFICER/MEMBER EXCLUDED? WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y / N AUTOMOBILE LIABILITY ANY AUTO ALL OWNED SCHEDULED HIRED AUTOS NON-OWNEDAUTOSAUTOS AUTOS COMBINED SINGLE LIMIT BODILY INJURY (Per person) BODILY INJURY (Per accident) PROPERTY DAMAGE $ $ $ $ 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. INSD ADDL WVD SUBR N / A $ $ (Ea accident) (Per accident) OTHER: 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). COVERAGES CERTIFICATE NUMBER:REVISION NUMBER: INSURED PHONE(A/C, No, Ext): PRODUCER ADDRESS:E-MAIL FAX(A/C, No): CONTACTNAME: NAIC # INSURER A : INSURER B : INSURER C : INSURER D : INSURER E : INSURER F : INSURER(S) AFFORDING COVERAGE SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. XXXXXX XXXXXX XXXXXX XXXXXX XXXXXX XXXXXX XXXXXX XXXXXX XXXXXX XXXXXX XXXXXX XXXXXX XXXXXX XXXXXX Not Applicable Not Applicable Not Applicable X A 12/29/2021 Baldwin Krystyn Sherman (iPEO) 4010 W Boy Scout Blvd Suite 200 Tampa, FL 33607 Technology Insurance Company 42376 Choice Employer Solutions, Inc. dba Fourth HR and Choice Employer Solutions III, Inc. dba Fourth HR 9007 Brittany Way Tampa , FL 33619 17547 01/19/202201/19/2021 1,000,000.00 1,000,000.00 TWC3945998 1,000,000.00 THIS CERTIFICATE CONFERS NO ADDITIONAL INSURED RIGHTS UPON THE CERTIFICATE HOLDER. Coverage is extended to the leased employees, not subcontractors, of Alternate Employer: Securance, LLC. DBA Securance Consulting (#CHR-973) at 13904 Monroes Business Park Tampa, FL 33635 effective 01/19/2021 as by contract. CHR-973 N City of Gilroy 7351 Rosanna Street Gilroy, CA 95020 DocuSign Envelope ID: 30850883-D9E8-4637-8872-EA867BAD3CC2 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. (This agreement applies only to the extent that you perform work under a written contract that requires you to obtain this agreement from us.) This agreement shall not operate directly or indirectly to benefit anyone not named in the Schedule. WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 00 03 13 (Ed. 04-84) Schedule Securance, LLC dba Securance Consulting City of Gilroy 7351 Rosanna Street Gilroy, CA. 95020 per written contract This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated. (The information below is required only when this endorsement is issued subsequent to preparation of the policy.) Endorsement Effective 12/13/2021 Policy No. TWC3945998 Endorsement No. 45 Insured Choice Employer Solutions, Inc. Insurance Company Technology Insurance Company, Inc. Countersigned by WC 00 03 13 (Ed. 04-84)          DocuSign Envelope ID: 30850883-D9E8-4637-8872-EA867BAD3CC2 Unique Market Reference No. B087520C9N5051, B087520C9N5053 © 1999-2019 CFC Underwriting Ltd, All Rights Reserved ATTACHING TO POLICY NUMBER:ESJ0028256007 THE INSURED:Securance, LLC WITH EFFECT FROM: 10 Feb 2021 It is understood and agreed that the following amendments are made to this Policy: 1. The following DEFINITION is added: ADDITIONAL INSURED ENDORSEMENT City of Gilroy (Effective From: 10 Dec 2021) 7351 Rosanna Street Gilroy, CA 95020 US 2. Where an “Additional insureds” CONDITION exists in this Policy, additional insureds are included as a third party. 3. Where an “Additional insureds” CONDITION does not exist in this Policy, the following CONDITION is added: Additional Insureds Additional insureds are indemnified under this Policy as if they were you, but only in respect of sums which they become legally obliged to pay (including liability for claimants’ costs and expenses) as a result of any claim arising solely out of an act, error or omission committed by you or on your behalf, provided that had the claim been made against you, then you would be entitled to indemnity under this Policy. Before we indemnify any additional insured, they must prove to us that the claim arose solely out of an act, error or omission committed by you or on your behalf and fully comply with CONDITION 1 as if they were you. When this CONDITION applies, it will be primary and non-contributory to the additional insured’s own insurance but only if you and the additional insured have entered into a contract that contains a provision requiring this. Whilst additional insureds are indemnified under this Policy, any claim made by additional insureds against you will be treated by us as if they were a third party and not as a named insured. 4. The following CONDITION is added: Notice of cancellation to additional insureds If we give you notice of cancellation in accordance with the “Cancellation” CONDITION, we will endeavour to provide the same notice of cancellation to additional insureds; however, not doing so will not place any additional liability upon us. SUBJECT OTHERWISE TO THE TERMS AND CONDITIONS OF THE POLICY Authorized Signatory CFC Underwriting Ltd DocuSign Envelope ID: 30850883-D9E8-4637-8872-EA867BAD3CC2 1 CFC Underwriting Ltd is Authorised and Regulated by the Financial Conduct Authority ©2018 CFC Underwriting Ltd, All Rights Reserved WAIVER OF SUBROGATION CLAUSE ATTACHING TO POLICY NUMBER: ESJ0028256007 THE INSURED: Securance, LLC WITH EFFECT FROM: 10 Dec 2021 Notwithstanding the “Our rights of recovery” CONDITION, we agree to waive our rights of subrogation against any third party but only where you and that third party have entered into a contract that contains a provision requiring us to do this. SUBJECT OTHERWISE TO THE TERMS AND CONDITIONS OF THE POLICY DocuSign Envelope ID: 30850883-D9E8-4637-8872-EA867BAD3CC2