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HomeMy WebLinkAboutCOI - Jet Mulch, Inc. - Expires 2023-04-01ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? INSR ADDL SUBR LTR INSD WVD PRODUCER CONTACT NAME: FAXPHONE (A/C, No):(A/C, No, Ext): E-MAIL ADDRESS: INSURER A : INSURED INSURER B : INSURER C : INSURER D : INSURER E : INSURER F : POLICY NUMBER POLICY EFF POLICY EXPTYPE OF INSURANCE LIMITS(MM/DD/YYYY)(MM/DD/YYYY) AUTOMOBILE LIABILITY UMBRELLA LIAB EXCESS LIAB WORKERS COMPENSATION AND EMPLOYERS' LIABILITY DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) AUTHORIZED REPRESENTATIVE EACH OCCURRENCE $ DAMAGE TO RENTEDCLAIMS-MADE OCCUR $PREMISES (Ea occurrence) MED EXP (Any one person)$ PERSONAL & ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER:GENERAL AGGREGATE $ PRO-POLICY LOC PRODUCTS - COMP/OP AGGJECT OTHER:$ COMBINED SINGLE LIMIT $(Ea accident) ANY AUTO BODILY INJURY (Per person)$ OWNED SCHEDULED BODILY INJURY (Per accident)$AUTOS ONLY AUTOS HIRED NON-OWNED PROPERTY DAMAGE $AUTOS ONLY AUTOS ONLY (Per accident) $ OCCUR EACH OCCURRENCE CLAIMS-MADE AGGREGATE $ DED RETENTION $ PER OTH- STATUTE ER E.L. EACH ACCIDENT E.L. DISEASE - EA EMPLOYEE $ If yes, describe under E.L. DISEASE - POLICY LIMITDESCRIPTION OF OPERATIONS below INSURER(S) AFFORDING COVERAGE NAIC # COMMERCIAL GENERAL LIABILITY Y / N N / A (Mandatory in NH) SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. 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. 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). COVERAGES CERTIFICATE NUMBER:REVISION NUMBER: CERTIFICATE HOLDER CANCELLATION © 1988-2015 ACORD CORPORATION. All rights reserved.ACORD 25 (2016/03) CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DD/YYYY) $ $ $ $ $ The ACORD name and logo are registered marks of ACORD 6/1/2022 License # 0E67768 (925) 660-3517 50010 (925) 416-7869 Jet Mulch, Inc P.O. Box 1667 Capitola, CA 95010 10120 10349 16045 A 1,000,000 X GLL1079201 4/1/2022 4/1/2023 100,000 5,000 1,000,000 2,000,000 2,000,000 1,000,000B CF1CA00318221 4/1/2022 4/1/2023 2,000,000C EMM000009902 4/1/2022 4/1/2023 2,000,000 D 7600020307221 4/1/2022 4/1/2023 1,000,000 Y 1,000,000 1,000,000 RE: Work shall include installation of engineered wood fiber for various City park playgrounds. City of Gilroy, its officers, officials and employees are Additional Insured with respect to General Liability, as required by written contract. City of Gilroy, its officers, officials and employees 7351 Rosanna Street Gilroy, CA 95020 JETMULC-01 THOMASRO IOA Insurance Services 3875 Hopyard Road Suite 200 Pleasanton, CA 94588 Mary Ann Cooksey MaryAnn.Cooksey@ioausa.com Lloyd's Everest National Insurance Company Acceptance Casualty Insurance Company Everest Premier Insurance Company X X X X X X X X X DocuSign Envelope ID: 15ED20DB-4D8B-482E-8033-1F4D3AD987D9 1 DocuSign Envelope ID: 15ED20DB-4D8B-482E-8033-1F4D3AD987D9 DocuSign Envelope ID: 15ED20DB-4D8B-482E-8033-1F4D3AD987D9 1 DocuSign Envelope ID: 15ED20DB-4D8B-482E-8033-1F4D3AD987D9 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. GL-0009 10 15 Includes copyrighted material of ISO Properties, Inc., with its Page 1 of 2 permission DESIGNATED CONSTRUCTION PROJECT(S) GENERAL AGGREGATE LIMIT WITH AGGREGATE CAP This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Designated Construction Project(s):Each construction project described in a separate written contract. Information required to complete this Schedule, if not shown above, will be shown in the Declarations. Designated Construction Project(s) Aggregate Cap For All Projects Combined: $ Information required to complete this Schedule, if not shown above, will be shown in the Declarations. A.For all sums which the insured becomes legally obligated to pay as damages caused by "occur- rences" under Section I Coverage A, and for all medical expenses caused by accidents under Section I Coverage C, which can be attributed only to ongoing operations at a single designated construction project shown in the Schedule above: 1.A separate Designated Construction Project General Aggregate Limit applies to each des- ignated construction project, and that limit is equal to the amount of the General Aggregate Limit shown in the Declarations. However, the separate Designated Construction Project General Aggregate Limits are subject to a Designated Construction Project General Ag- gregate Cap For All Projects Combined in the amount shown in the schedule of this en- dorsement. The Designated Construction Pro- ject General Aggregate Cap For All Projects Combined is the maximum amount we will pay under the General Aggregate Limit for all claims arising from all Designated Construc- tion Projects combined. 2.The Designated Construction Project General Aggregate Limit is the most we will pay for the sum of all damages under Coverage A, ex- cept damages because of "bodily injury" or "property damage" included in the "products- completed operations hazard", and for medi- cal expenses under Coverage C regardless of the number of: a.Insureds; b.Claims made or "suits" brought; or c.Persons or organizations making claims or bringing "suits". 3. Any payments made under Coverage A for damages or under Coverage C for medical expenses shall reduce the Designated Con- struction Project General Aggregate Limit for that designated construction project and the Designated Construction Project General Ag- gregate Cap For All Projects. Such payments shall not reduce the General Aggregate Limit shown in the Declarations nor shall they re- duce any other Designated Construction Pro- ject General Aggregate Limit for any other designated construction project shown in the DocuSign Envelope ID: 15ED20DB-4D8B-482E-8033-1F4D3AD987D9 GL-0009 10 15 Includes copyrighted material of ISO Properties, Inc., with its Page 2 of 2 permission Schedule above. However, such payments for damages and medical expenses included in the Designated Construction Project General Aggregate Limit for all designated construc- tion projects combined will reduce the Desig- nated Construction Project General Aggre- gate Cap For All Projects. 4. The limits shown in the Declarations for Each Occurrence, Damage To Premises Rented To You and Medical Expense continue to apply. However, instead of being subject to the General Aggregate Limit shown in the Decla- rations, such limits will be subject to the appli- cable Designated Construction Project Gen- eral Aggregate Limit. B.For all sums which the insured becomes legally obligated to pay as damages caused by "occur- rences" under Section I Coverage A, and for all medical expenses caused by accidents under Section I Coverage C, which cannot be at- tributed only to ongoing operations at a single designated construction project shown in the Schedule above: 1. Any payments made under Coverage A for damages or under Coverage C for medical expenses shall reduce the amount available under the General Aggregate Limit or the Products-completed Operations Aggregate Limit, whichever is applicable; and 2. Such payments shall not reduce any Desig- nated Construction Project General Aggre- gate Limit. C. When coverage for liability arising out of the "products-completed operations hazard" is pro- vided, any payments for damages because of "bodily injury" or "property damage" included in the "products-completed operations hazard" will reduce the Products-completed Operations Ag- gregate Limit, and not reduce the General Ag- gregate Limit nor the Designated Construction Project General Aggregate Limit. D. If the applicable designated construction project has been abandoned, delayed, or abandoned and then restarted, or if the authorized contract- ing parties deviate from plans, blueprints, de- signs, specifications or timetables, the project will still be deemed to be the same construction pro- ject. E. The provisions of Section III Limits Of Insur- ance not otherwise modified by this endorsement shall continue to apply as stipulated. DocuSign Envelope ID: 15ED20DB-4D8B-482E-8033-1F4D3AD987D9