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HomeMy WebLinkAboutCOI - Alpha Analytical Laboratories, Inc. - Expires 2023-06-04ANY 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 9/29/2022 (707) 462-5901 (707) 462-3763 Alpha Analytical Laboratories, Inc. 208 Mason St. Ukiah, CA 95482 42579 11512 A 3,000,000 X X ENV562004850-01 4/6/2022 4/6/2023 100,000 X, C, U Included 5,000 3,000,000 3,000,000 3,000,000 1,000,000B ACPBA7830172096 11/1/2021 11/1/2022 2,000,000A ENV562004851-01 4/6/2022 4/6/2023 2,000,000 0 C X EIG261089204 5/1/2022 5/1/2023 1,000,000 Y 1,000,000 1,000,000 A Professional Liab ENV562004850-01 4/6/2022 Ea. Occ./Aggregate 3,000,000 A Pollution Liability ENV562004850-01 4/6/2022 4/6/2023 Ea. Occ./Aggregate 3,000,000 RE: City of Gilroy Pretreatment Wastewater Processing City of Gilroy, its officers, representatives, agents and employees are named as an Additional Insured on the general liability. Waiver of Subrogation and Primary Wording applies. City of Gilroy 7351 Rosanna Street Gilroy, CA 95020 ALPHANA-01 ADELAPO Team Insurance & Financial Services, Inc. PO Box 1472 Ukiah, CA 95482 Ashley DeLapo ashley@teamins.net Guideone Insurance Nationwide Mutual Insurance Company Employers Comp Ins Co X 4/6/2023 X X X X X X X X DocuSign Envelope ID: EF42E6CC-66A3-4405-92ED-780CD5F6ED92 POLICY NUMBER: ENV562004850-01 COMMERCIAL GENERAL LIABILITY CG 20 10 07 04 CG 20 10 07 04 © ISO Properties, Inc., 2004. Page 1 of 1 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - OWNERS, LESSEES OR CONTRACTORS - SCHEDULED 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): Location(s) Of Covered Operations Any person or organization for whom you are performing operations when you and such person or organization have agreed in writing in a contract or agreement, effected prior to the date your operations for that person or organization commenced, that such person or organization be added as an additional insured on your policy. In respect to any location where the named insured is performing “your work”. 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: 1.Your acts or omissions; or 2.The acts or omissions of those acting on your behalf; in the performance of your ongoing operations for the additional insured(s) at the location(s) designated above. B.With respect to the insurance afforded to these additional insureds, the following additional exclu- sions apply: This insurance does not apply to "bodily injury" or "property damage" occurring after: 1. All work, including materials, parts or equip- ment 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 location 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 in- tended 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. DocuSign Envelope ID: EF42E6CC-66A3-4405-92ED-780CD5F6ED92 POLICY NUMBER: ENV562004850-01 COMMERCIAL GENERAL LIABILITY CG 20 37 07 04 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. CG 20 37 07 04 © ISO Properties, Inc., 2004 Page 1 of 1 – ADDITIONAL INSURED OWNERS, LESSEES OR – CONTRACTORS COMPLETED OPERATIONS This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Name Of Additional Insured Person(s) Or Organization(s):Location And Description Of Completed Operations Any person or organization for whom you are performing operations when you and such person or organization have agreed in writing in a contract or agreement, effected prior to the date your operations for that person or organization commenced, that such person or organization be added as an additional insured on your policy. In respect to any location where the named insured is performing “your work”. Information required to complete this Schedule, if not shown above, will be shown in the Declarations. – 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" or "property damage" caused, in whole or in part, by "your work" at the location designated and described in the schedule of this endorsement performed for that additional insured and included in the "products- completed operations hazard". DocuSign Envelope ID: EF42E6CC-66A3-4405-92ED-780CD5F6ED92 GO 0218 – 4YA 10-17 Includes Copyrighted Material of Insurance Services Office, Inc. with its permission Page 1 of 1 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. AMENDED WAIVER OF SUBROGATION This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Name of Person or Organization: Any person or organization that is: 1.An owner of real or personal property on which you are performing operations,but only at the specific written request by that person or organization to you, and only if: a.That request is made prior to the date your operations for that person or organization commenced; and b.A Certificate of Insurance evidencing that request has been issued by your authorized insurance agent or broker; or 2.A contractor on whose behalf you are performing operations,but only at the specific written request by that person or organization to you, and only if: a.That request is made prior to the date your operations for that person or organization commenced; and b.A Certificate of Insurance evidencing that request has been issued by your authorized insurance agent or broker. WAIVER OF SUBROGATION –If required by written contract or agreement,we waive any right of recovery we may have against any entity that is an additional insured shown in the Schedule above per the terms of this endorsement because of payments we make for injury or damage arising out of “your work”performed under a contract with that person or organization. All other terms and conditions remain unchanged. DocuSign Envelope ID: EF42E6CC-66A3-4405-92ED-780CD5F6ED92 GO 0216 – 4YP 10-17 Includes Copyrighted Material of Insurance Services Office, Inc. with its permission Page 1 of 1 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. PRIMARY/NON-CONTRIBUTORY COVERAGE This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART PRIMARY/NON-CONTRIBUTORY –If required by written contract or agreement,effected prior to the date your operations for that person or organization commenced and named below, such insurance as is afforded by this policy to any additional insureds under this policy shall be primary insurance,and any insurance or self-insurance maintained by such additional insured(s)shall not contribute to the insurance afforded to the named insured. All other terms and conditions remain unchanged. SCHEDULE Any person or organization that is: 1.An owner of real or personal property on which you are performing operations,but only at the specific written request by that person or organization to you, and only if: a.That request is made prior to the date your operations for that person or organization commenced;and b.A Certificate of Insurance evidencing that request has been issued by your authorized insurance agent or broker; or 2.A contractor on whose behalf you are performing operations,but only at the specific written request by that person or organization to you, and only if: a.That request is made prior to the date your operations for that person or organization commenced;and b.A Certificate of Insurance evidencing that request has been issued by your authorized insurance agent or broker. DocuSign Envelope ID: EF42E6CC-66A3-4405-92ED-780CD5F6ED92                                         DocuSign Envelope ID: EF42E6CC-66A3-4405-92ED-780CD5F6ED92