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HomeMy WebLinkAboutCOI - Applied Survey Research, Inc. - Expires 2022-10-011 A�'� ® DATE (MM/DD/YYYY) �� CERTIFICATE OF LIABILITY INSURANCE Acct# 2751717 10/01/2021 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 CONTACT Lockton Companies, LLC PHONE FAX -- - - - 3657 Briarpark Dr., Suite 700 _(A/C• No, Exti: 888-828-8365 (luc, Noy_ E-MAIL Houston, TX 77042 ADDRESS: _ INSURERS) AFFORDING COVERAGE _ NAIC # INSURER A: Indemnity Insurance Co. of North America 43575 INSURED INSURER B APPLIED SURVEY RESEARCH, INC. — — 55 PENNY LN STE 101 INSURER C : WATSONVILLE, CA 95076-6017 - -- INSURER 0 INSURER E : INSURER F : CGVFRAGFS CFRTIFICATF N11MRFR• 12FVIC1nKI Kill 11UR1=R- 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 ADD LiSUBR - POLICY EFF POLICY EXP WVDPOLICY NUMBER MM/DD/YYYY MM/DD/YYYY LIMITS COMMERCIAL GENERAL LIABILITY -- l-EACH OCCURRENCE I S J CLAIMS -MADE OCCUR DAMAGE TO RENTED PREMISES Ea occurrence S ( ) - -- rMED EXP (Any one person) �$ PERSONAL & ADV INJURY I $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE S PRO- _ POLICY JECT I _ J PRODUCTS - COMP/OP AGG 1 $ OTHER: - $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT S - i (Ea accidenil- ANY AUTO I _ -__, BODILY INJURY (Per person) $ ALL OWNED SCHEDULED �{ AUTOS AUTOS nt) S BODILY INJURY Per accident) ( NON OWNED HIRED AUTOS �j AUTOS jl __ PROPERTY DAMAGE $ (Per accident)_ _ -_I I Is UMBRELLA LIAB OCCUR EACH OCCURRENCE S __ EXCCEESS�LIAB CLAIMS -MADE! AGGREGATE S DED I RETENTION $, is WORKERS COMPENSATION X I PER OTH- AND EMPLOYERS' LIABILITY Y / N STATUTE ER ANY PROPRIETOR/PARTNER/EXECUTIVE A OFFICER/MEMBER N / A X E.L. EACH ACCIDENT C70120446 10/01 /2021 10/01 /2022 �- - - - $ 1,000.000 - - EXCLUDED? (Mandatory in NH) E.L. DISEASE - EA EMPLOYE $ 1,000,000 If yes, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE -POLICY LIMIT S t,000.000 1 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) WAIVER OF SUBROGATION IN FAVOR OF City of Gilroy its Officers, Employees and Representatives WHEN REQUIRED BY WRITTEN CONTRACT. GtH 111-IGA I t MULUEH CITY OF GILROY ITS OFFICERS, EMPLOYEES AND REPRESENTATIVES 7351 ROSANNA STREET GILROY , CA 95020 ACORD 25 (2016/03) 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 ©1988-2014 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD Workers' Compensation and Employers' Liability Policy Named Insured Endorsement Number Insperity, Inc. L/C/F Policy Number APPLIED SURVEY RESEARCH, INC. 19001 Crescent Springs Drive Symbol: RWC Number: C70120446 Kingwood, TX 77339 Policy Period Effective Date of Endorsement 10/01 /2021 TO 10/01 /2022 10/01 /2021 Issued By (Name of Insurance Company) Indemnity Insurance Co. of North America Insert the policy number. The remainder of the information is to be completed only when this endorsement is issued subsequent to the preparation of the policy. CALIFORNIA WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT This endorsement applies only to the insurance provided by the policy because California is shown in Item 3.A. of the Information Page. 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, but this waiver applies only with respect to bodily injury arising out of the operations described in the Schedule, where you are required by a written contract to obtain this waiver from us. You must maintain payroll records accurately segregating the remuneration of your employees while engaged in the work described in the Schedule. Schedule 1. ( X) Specific Waiver Name of person or organization: City of Gilroy its Officers, Employees and Representatives 7351 Rosanna Street Gilroy, CA 95020 ( } Blanket Waiver Any person or organization for whom the Named Insured has agreed by written contract to furnish this waiver. 2. Operations: 3. Premium: The premium charge for this endorsement shall be INCLUDED percent of the California premium developed on payroll in connection with work performed for the above person(s) or organization(s) arising out of the operations described. 4. Minimum Premium: INCLUDED Authorized- epresen a ive WC 99 03 22