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HomeMy WebLinkAboutCOI - Empowering Our Community for Success - Expires 2023-07-20SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. INSURER(S) AFFORDING COVERAGE INSURER F : INSURER E : INSURER D : INSURER C : INSURER B : INSURER A : NAIC # NAME:CONTACT (A/C, No):FAX E-MAILADDRESS: PRODUCER (A/C, No, Ext):PHONE INSURED REVISION NUMBER:CERTIFICATE NUMBER:COVERAGES 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). 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. OTHER: (Per accident) (Ea accident) $ $ N / A SUBR WVD ADDL INSD 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. $ $ $ $PROPERTY DAMAGE BODILY INJURY (Per accident) BODILY INJURY (Per person) COMBINED SINGLE LIMIT AUTOS ONLY AUTOSAUTOS ONLY NON-OWNED SCHEDULEDOWNED ANY AUTO AUTOMOBILE LIABILITY Y / N WORKERS COMPENSATION AND EMPLOYERS' LIABILITY OFFICER/MEMBER EXCLUDED? (Mandatory in NH) DESCRIPTION OF OPERATIONS below If yes, describe under ANY PROPRIETOR/PARTNER/EXECUTIVE $ $ $ E.L. DISEASE - POLICY LIMIT E.L. DISEASE - EA EMPLOYEE E.L. EACH ACCIDENT EROTH-STATUTEPER LIMITS(MM/DD/YYYY)POLICY EXP(MM/DD/YYYY)POLICY EFFPOLICY NUMBERTYPE OF INSURANCELTRINSR DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) EXCESS LIAB UMBRELLA LIAB $EACH OCCURRENCE $AGGREGATE $ OCCUR CLAIMS-MADE DED RETENTION $ $PRODUCTS - COMP/OP AGG $GENERAL AGGREGATE $PERSONAL & ADV INJURY $MED EXP (Any one person) $EACH OCCURRENCE DAMAGE TO RENTED $PREMISES (Ea occurrence) COMMERCIAL GENERAL LIABILITY CLAIMS-MADE OCCUR GEN'L AGGREGATE LIMIT APPLIES PER: POLICY PRO-JECT LOC CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DD/YYYY) CANCELLATION AUTHORIZED REPRESENTATIVE ACORD 25 (2016/03) © 1988-2015 ACORD CORPORATION. All rights reserved. CERTIFICATE HOLDER The ACORD name and logo are registered marks of ACORD HIRED AUTOS ONLY 10/18/2022 Pacific Diversified Insurance Services 15005 Concord Circle Ste 110 Morgan Hill CA 95037 Shannon Gwinn 408-842-2131 408-842-0867 sgwinn@pdins.com License#:0K07568 Northfield Insurance Company 27987 EMPOOUR-02 Empowering Our Community for Success 1711 Warburton Ave #5 Santa Clara CA 95050 418769018 A X 1,000,000 X 100,000 5,000 1,000,000 2,000,000 X Y WS527207 7/20/2022 7/20/2023 2,000,000 A 1,000,000 X X WS527207 7/20/2022 7/20/2023 A Abuse or Molestation Assault or Battery Professional Liability Y Y Y WS527207 7/20/2022 7/20/2023 Aggregate Aggregate Aggregate 1,000,000 1,000,000 2,000,000 “CITY OF GILROY,its officers and employees”as additional insureds on the Comprehensive Liability insurance policy referred to in (a)immediately above via a specific endorsement. City of Gilroy 7351 Rosanna Street Gilroy CA 95020 DocuSign Envelope ID: 2724433C-2D43-4484-BDFC-F883F9CDC376 STATE COMPENSATION INSURANCE FUND FEBRUARY 8, 2023 CITY OF GILROY 7351 ROSANNA ST GILROY CA 95020-6141 IN REPLY REFER TO: RE FEB 1 4 2023 GILROY CITY CLERK'S OFFICE CERTIFICATE OF WORKERS' COMPENSATION INSURANCE CANCELLATION WITHDRAWAL NOTICE RE: CERTIFICATE DATED OCTOBER 21, 2022 THE CANCELLATION HAS BEEN WITHDRAWN FOR THE WORKERS' COMPENSATION INSURANCE POLICY FOR THE EMPLOYER NAMED BELOW. THIS LETTER SUPERSEDES THE NOTICE OF CANCELLATION SENT TO YOU ON JANUARY 27, 2023. THIS EMPLOYER'S WORKERS' COMPENSATION INSURANCE COVERAGE CONTINUED UNINTERRUPTED. EMPLOYER: EMPOWERING OUR COMMUNITY FOR SUCCE 1711 WARBURTON AVE APT 5 SANTA CLARA, CA 95050 POLICY 9261123-22 CUSTOMER SERVICE REPRESENTATIVE CUSTOMER SERVICE CENTER (888) 782-8338 5860 Owens Dr Pleasanton, CA 94588-3900 Mailing Address: P.O. Box 8192 • Pleasanton, CA 94588-9682 SCIF 19102 DocuSign Envelope ID: 2724433C-2D43-4484-BDFC-F883F9CDC376 DocuSign Envelope ID: 2724433C-2D43-4484-BDFC-F883F9CDC376 DocuSign Envelope ID: 2724433C-2D43-4484-BDFC-F883F9CDC376 DocuSign Envelope ID: 2724433C-2D43-4484-BDFC-F883F9CDC376 DocuSign Envelope ID: 2724433C-2D43-4484-BDFC-F883F9CDC376 DocuSign Envelope ID: 2724433C-2D43-4484-BDFC-F883F9CDC376 DocuSign Envelope ID: 2724433C-2D43-4484-BDFC-F883F9CDC376 DocuSign Envelope ID: 2724433C-2D43-4484-BDFC-F883F9CDC376 DocuSign Envelope ID: 2724433C-2D43-4484-BDFC-F883F9CDC376 DocuSign Envelope ID: 2724433C-2D43-4484-BDFC-F883F9CDC376 DocuSign Envelope ID: 2724433C-2D43-4484-BDFC-F883F9CDC376 DocuSign Envelope ID: 2724433C-2D43-4484-BDFC-F883F9CDC376 DocuSign Envelope ID: 2724433C-2D43-4484-BDFC-F883F9CDC376 DocuSign Envelope ID: 2724433C-2D43-4484-BDFC-F883F9CDC376 DocuSign Envelope ID: 2724433C-2D43-4484-BDFC-F883F9CDC376 DocuSign Envelope ID: 2724433C-2D43-4484-BDFC-F883F9CDC376 DocuSign Envelope ID: 2724433C-2D43-4484-BDFC-F883F9CDC376 DocuSign Envelope ID: 2724433C-2D43-4484-BDFC-F883F9CDC376 DocuSign Envelope ID: 2724433C-2D43-4484-BDFC-F883F9CDC376 DocuSign Envelope ID: 2724433C-2D43-4484-BDFC-F883F9CDC376 NA ISSUE DATE: 10-21-2022 9261123-2022 8 09-20-2023 09-20-2022/09-20-2023 CITY OF GILROY NA 7351 ROSANNA ST GILROY CA 95020-6141 10 10 EMPLOYER'S LIABILITY LIMIT INCLUDING DEFENSE COSTS: $1,000,000 PER OCCURRENCE. EMPOWERING OUR COMMUNITY FOR SUCCESS (A NON PROFIT PUBLIC BENEFIT CORP) 1711 WARBURTON AVE APT 5 SANTA CLARA CA 95050 PRINTED : 10-21-2022 CERTHOLDER COPY [DH6,CN] DocuSign Envelope ID: 2724433C-2D43-4484-BDFC-F883F9CDC376 NA ISSUE DATE: 10-21-2022 9261123-2022 8 09-20-2023 09-20-2022/09-20-2023 CITY OF GILROY NA 7351 ROSANNA ST GILROY CA 95020-6141 10 10 EMPLOYER'S LIABILITY LIMIT INCLUDING DEFENSE COSTS: $1,000,000 PER OCCURRENCE. EMPOWERING OUR COMMUNITY FOR SUCCESS (A NON PROFIT PUBLIC BENEFIT CORP) 1711 WARBURTON AVE APT 5 SANTA CLARA CA 95050 PRINTED : 10-21-2022 POLICYHOLDER COPY [DH6,CN] DocuSign Envelope ID: 2724433C-2D43-4484-BDFC-F883F9CDC376