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HomeMy WebLinkAboutCOI - Choice Employer Solutions, Inc. - Expires 2024-01-19ACQ CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DD/YYYY) 01/19/2023 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). PRODUCER Andrew Atsaves c/o Artex Risk Solutions, Inc. P.O. Box 13838 Scottsdale, AZ 85267 INSURED Choice Employer Solutions, Inc. dba: Fourth HR Alt. Emp: Securance, LLC dba: Securance Consulting 9007 Brittany Way Tampa, FL 33619 CONTACT NAME: PHONE 480 951-4177 FAX �A/C No EA,I: ( ) (A/C, No): (480) 951-4266 ADDR E-MAIL ESS: SDL.BSD.Certificates@artexrisk.com INSURER(S) AFFORDING COVERAGE NAIC INSURERA: American Zurich Insurance Company _ 40142 INSURER B : INSURER C : INSURER D : INSURER E : INSURER F : COVERAGES CERTIFICATE NUMBER:23FL0861141894 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 LTR TYPE OF INSURANCE ADDL INSD SUBR WVD POLICY NUMBER POLICY EFF (MMIDD/YYYY) POLICY EXP (MM/DD/YYYY) LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1 CLAIMS -MADE I OCCUR DAMAGE TO RENTED PREMISES (Ea occurrence) $ _ MED EXP (Any one person) $ PERSONAL & ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: J LOC GENERAL AGGREGATE $ PRODUCTS - COMP/OP AGG $ $ AUTOMOBILE _. _ LIABILITY ANY AUTO OWNED AUTOS ONLY HIRED ISCHEDULED AUTOS NON -OWNED AUTOS ONLY COMBINED SINGLE LIMIT jga accident) $ BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ PROPERTY DAMAGE (Per accident) $ $ UMBRELLA LIAB EXCESS LIAB DED I 1 RETENT ON $ OCCUR CLAIMS -MADE EACH OCCURRENCE $ AGGREGATE $ $ A WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANYPROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below Y / N N/A X WC 23-07-669-00 01/19/2023 01/19/2024 Si PER I OTH- STATUTE f_ ER E.L. EACH ACCIDENT $ 1,000,000 E.L. DISEASE - EA EMPLOYEE', $ 1,000,000 E.L. DISEASE - POLICY LIMIT ' $ 1,000,000 Location Coverage Period: 01/19/2023 01/19/2024 Client# 973-FL DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) Coverage is provided for Securance, LLC dba: Securance Consulting Waiver of subrogation is added to the policy in favor of: Securance LLC 13904 Monroes only those co -employees 6922 W Linebaugh Ave Business Park Tampa, FL 33635 Cert Holder: City of Gilroy 7351 Rosanna Street of, but not subcontractors Tampa, FL 33625 Gilroy, CA 95020 to: Endorsements: Waiver of Subrogation CERTIFICATE HOLDER City of Gilroy 7351 Rosanna ST Gilroy, CA 95020 IJAN 2 7 2023 GILROY CITY CLERK'S OFFICE RE CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE © 1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD WORKERS' COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 04 03 06 (Ed. 4-84) WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT — CALIFORNIA 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 per- form work under a written contract that requires you to obtain this agreement from us.) You must maintain payroll records accurately segregating the remuneration of your employees while engaged in the work described in the Schedule. The additional premium for this endorsement shall be $o of the California workers' compensation premium otherwise due on such remuneration. SCHEDULE Person or Organization Job Description IN FAVOR OF: City of Gilroy 7351 Rosanna ST Gilroy, CA 95020 Waiver of subrogation is added to the policy in favor of: Securance LLC 13904 Monroes Business Park Tampa, FL 33635 Cert Holder: City of Gilroy 7351 Rosanna Street Gilroy, CA 95020 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: 01/19/2023 Policy No: WC 23-07-669-00 Endorsement No: Insured: Choice Employer Solutions, Inc. dba: Fourth HR Alt. Emp: Securance, LLC dba: Securance Consulting Insurance Company: American Zurich Insurance Company Countersigned by WC 04 03 06 Copyright 1983 National Council on Compensation Insurance 000000 02 02 007025 020340 P