HomeMy WebLinkAboutCOI - Personal Impressions - Expires 2023-11-01CERTHOLDER COPY
NA
P.O. BOX 8192, PLEASANTON, CA 94588
CERTIFICATE OF WORKERS' COMPENSATION INSURANCE
ISSUE DATE: 11-01-2022 In<I��C. �SLI VIED GROUP:
POLICY NUMBER: 9085403-2022
OCT 26 lULC CERTIFICATE ID: 22
CERTIFICATE EXPIRES: 11-01-2023
11-01-2022/11-01-2023
GILROY CITY CLERICS OFFICE
CITY OF GILROY NA
7301 HANNA ST
GILROY CA 95020-6129
This is to certify that we have issued a valid Workers' Compensation insurance policy in a form approved by the
Cahfoinid insurance Cornmissioncr to the employer named below for the policy period indicated.
This policy is not subject to cancellation by the Fund except upon 10 days advance written notice to the employer.
We will also give you 10 days advance notice should this policy be cancelled prior to its normal expiration.
This certificate of insurance is not an insurance policy and does not amend, extend or alter the coverage afforded
by the policy listed herein. Notwithstanding any requirement, term or condition of any contract or other document
with respect to which this certificate of insurance may be issued or to which it may pertain, the insurance
afforded by the policy described herein is subject to all the terms, exclusions, and conditions, of such policy.
Authorized Representative President and CEO
UNLESS INDICATED OTHERWISE BY ENDORSEMENT, COVERAGE UNDER THIS POLICY EXCLUDES THE FOLLOWING:
THOSE NAMED IN THE POLICY DECLARATIONS AS AN INDIVIDUAL EMPLOYER OR A HUSBAND AND WIFE EMPLOYER;
EMPLOYEES COVERED ON A COMPREHENSIVE PERSONAL LIABILITY INSURANCE POLICY ALSO AFFORDING
CALIFORNIA WORKERS' COMPENSATION BENEFITS; EMPLOYEES EXCLUDED UNDER CALIFORNIA WORKERS'
COMPENSATION LAW.
EMPLOYER'S LIABILITY LIMIT INCLUDING DEFENSE COSTS: $1,000,000 PER OCCURRENCE.
ENDORSEMENT H2570 ENTITLED WAIVER OF SUBROGATION EFFECTIVE 2022-11-01 IS
ATTACHED TO AND FORMS A PART OF THIS POLICY. THIRD PARTY NAME:
CITY OF GILROY
EMPLOYER
COLLINS, TIMOTHY K OBA: PERSONAL IMPRESSIONS
331 EL CERRITO WAY
GILROY CA 95020
M0408
(REVJ-2014) PRINTED : 10-17-2022