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Home My WebLink AboutCOI - Quirino Vazquez - Expires 2022-11-27>® CERTIFICATE OF LIABILITY INSURANCE I DATE (MM/DD/YYYY) --, 6/6/2022 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). PRODUCER ~~AAI~~• Zenaida Belnas Scurich Insurance Services PHONE (831) 661-5697 I FAX /A/C No. Extl: /A/C Nol: (831) 661-5741 License #0436405 ~mJ~ss: zenaida@scurichinsurance.com P.O. Box 1170 INSURER($} AFFORDING COVERAGE NAIC# Watsonville CA 95077-1170 INSURER A: Ohio Securi tv Insurance Companv INSURED INSURER B: American Fire & Casual tv Co Quirino Vazquez INSURERC:State Compensation Insurance Fund of C1 00123 835 Green Valley Road INSURERD: INSURERE: Watsonville CA 95076 INSURERF: COVERAGES CERTIFICATE NUMBER: CL226607032 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 ADDL SUBR 1 POLICYEFF POLICY EXP LIMITS LTR TYPE OF INSURANCE "'"n I\An1n POLICY NUMBER MM/DD/YYYYl IMM/DD/YYYYl X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 I CLAIMS-MADE LJLl OCCUR DAMAGE TO RENTED 200,000 A PREMISES (Ea occurrence\ $ BKS(22)60254525 11/27/2021 11/27/2022 ...__ MED EXP (Any one person) $ 15,000 ,___ PERSONAL & ADV INJURY $ 1,000,000 GEN'LAGGREGATE LIMIT APPLIES PER: GENERALAGGREGATE $ 2,000,000 ~ POLICY □ ~r8-r □ LOG PRODUCTS -COMP/OP AGG $ 2,000,000 OTHER: Emp Practices Liability $ 10,000 AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ 1,000,000 /Ea accident) ,___ ANY AUTO BODILY INJURY (Per person) $ A ,___ ALL OWNED -SCHEDULED BAS(22)60254525 11/27/2021 11/27/2022 BODILY INJURY (Per accident) $ ...__ AUTOS ,__ AUTOS X X NON-OWNED PROPERTY DAMAGE $ HIRED AUTOS AUTOS (Per accident) ,___ ,__ $ X UMBRELLA LIAB H OCCUR EACH OCCURRENCE $ 1,000,000 B EXCESS LIAB CLAIMS-MADE AGGREGATE $ 1,000,000 DED I X I RETENTION $ 10,000 USA60254525 5/9/2022 11/27/2022 $ WORKERS COMPENSATION XI r~%uTE I I OTH- AND EMPLOYERS" LIABILITY ER Y/N ANY PROPRIETOR/PARTNER/EXECUTIVE □ E.L. EACH ACCIDENT $ 1,000,000 OFFICER/MEMBER EXCLUDED? N/A C (Mandatory in NH) 9090477-2022 6/1/2022 6/1/2023 E.L. DISEASE -EA EMPLOYEE $ 1,000,000 If yes, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE -POLICY LIMIT $ 1.000 000 DESCRIPTION OF OPERATIONS/ LOCATIONS /VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) re Project: 311 Lewis Street, Gilroy, CA, 95020 The City of Gilroy, its officers, officials, and employees are additional insureds per the attached endorsement CG 88 10 04 13. CERTIFICATE HOLDER CANCELLATION ,;/ SHOULD ANY OF THE ABOVE DESCRIBED POLICIIES BE CANCELLED BEFORE City of Gilroy 7351 Rosanna Street Gilroy, CA I ACORD 25 (2014/01) INS025 (201401) 95020 THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE Antone Scurich/VIKKI (lnlf;;;,~~ © 1988-2014 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD r--------------------------------------------------------------------------, Additional Named Insureds Other Named Insureds Club Vasco de Quiroga Not for profit org Four Seasons Gardening Individual, Doing Business As La Michuacana Taqueria Individual, Doing Business As Pacas Tacos Individual, Doing Business As Taqueria Monarca Individual, Doing Business As OFAPPINF (02/2007) COPYRIGHT 2007, AMS SERVICES INC -~ ADDITIONAL COVERAGES Ref# I Description I Coverage Code Form No. I Edition Date Liquor Liability LIQUR Limit 1 I Limit2 I Limit3 I Deductible Amount I Deductible Type Premium 1,000,000 Ref# I Description I Coverage Code Form No. I Edition Date Surcharges SURC Limit 1 I Limit2 I Limit 3 I Deductible Amount I Deductible Type Premium $563.04 Ref# I Description I Coverage Code Form No. I Edition Date Premium discount POIS Limit 1 I Limit2 I Limit 3 I Deductible Amount I Deductible Type Premium Ref# I Description I Coverage Code Form No. I Edition Date Rate Modification Factor RMF Limit 1 I Limit2 I Limit3 I Deductible Amount I Deductible Type Premium -$5,257.04 Ref# I Description I Coverage Code Form No. I Edition Date Experience Mod Factor 1 EXP01 Limit 1 I Limit2 I Limit3 I Ded\~ctible Amount' I Deductible Type Premium Ref# I Description I Coverage Code Form No. I Edition Date Limit 1 I Limit 2 I Limit 3 I Deductible Amount I Deductible Type Premium Ref# I Description I Coverage Code Form No. I Edition Date Limit 1 I Limit2 I Limit 3 I Deductible Amount I Deductible Type Premium Ref# I Description I Coverage Code Form No. I Edition Date Limit 1 I Limit2 I Limit3 I Deductible Amount I Deductible Type Premium Ref# I Description I Coverage Code Form No . I Edition Date Limit 1 I Limit2 I Limit3 I Deductible Amount . 1 Deductible Type Premium Ref# I Description I Coverage Code Form No. I Edition Date Limit 1 I Limit2 I Limit3 I Deductible Amount I Deductible Type Premium Ref# I Description I Coverage Code Form No. I Edition Date Limit 1 I Limit2 I Limit3 I Deductible A~;''>unt I Deductible Type Premium OFADTLCV Copyright 2001, AMS Services, Inc.