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HomeMy WebLinkAboutCOI - Empire Southwest, LLC - Expires 2022-07-01EMPISOU-01 MMORIN '4�oRo CERTIFICATE OF LIABILITY INSURANCE DATE (MM/021YY) 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 NQTEACT ARNETT INSURANCE SERVICES, LLC PHONE - FAX -- - 3850 E BASELINE RD #106 A/c, No, Ex9:_(480) 830-7400 - ,v( C, Noy.(480) 830-7404 - - MESA, AZ 85206 E-MAIL-mmorinnnarnettins.com 9DDRESS, -- - ___ - - _ INSURER(S) AFFORDING COVERAGE _- NAIC # INSURER A: Ace American INSURED INSURER B : Great American Ins Co - 16691 Empire Southwest, LLC INSURER c : 1725 S Country Club Dr INSURER D: -- -- - - - - - Mesa, AZ 85210 _ INSURER E INSURER F : l_nVFRAnPQ rF:PTIFIrATG KIIIMRFR• 12FVICInk1 IUI IMRFR• 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. SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. _LIMITS - LTR TYPE OF INSURANCE - - ADDL SUER _ - - INSR � POLICY NUMBER -- - - - - - - POLICY EFF POLICY EXP LIMITS A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ CLAIMS -MADE I X 1 OCCUR -- X HDOG7249099A 711/2021 7/1/2022 DAMAGE TO RENTED PREMISES (Ea occu�enc.e) 300,000 ! $ - --- - -- -- MED EXP (Any one person _ $ 10,000 PERSONAL& ADV INJURY 2,000,000_ , $ --__-_ GATE LIMIT APPLIES PER: GEN'L AGGREGATE GENERAL AGGREGATE 4,000,000 $ X POLICY X 1 j �T — LOC PRODUCTS - COMP/OP AGG _ $ 4,000,000 DE GIS NATED LOC 3,000,000 OTHER: $ A AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT 2,000,000 i�Ea cci nt}- - • $ X j ANY AUTO X !ISAH25552635 7/1/2021 7/1/2022 BODILY INJURY _(Per personi - - $ - -- OWNED i SCHEDULED AUTOS ONLY f AUTOS _BODILY INJURY (Per accident)] $ AURED p�/NEp TOS ONLY _ _ _.. AUTOS ONLY PROPERTY AMAGE (Per acc�dent�_ $ B I UMBRELLA LIAB X OCCUR EACH OCCURRENCE $5,000,000 AGGREGATE X i EXCESS LIAR CLAIMS -MADE TUE478499214 7/1/2021 7/112022 $ 5,000,000 DED RETENTION $ $ A WORKERS COMPENSATION X PER ERH AND EMPLOYERS' LIABILITY YIN WLRC67814699 7/1/2021 7/1/2022 STAT_UTE - 2,000,000 ANY E.L.EACH ACCIDENT'_— $ FFIdato n BER EXCLUDED? N �A WORCER rM fET H'/PARTNER/EXECUTIVE E E. - 2,000,000 E L. DISEASE - EA EMPLOYEE$ $ . Ues, describe under SCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT 2,000,000 $ A 4Phy Dmg USAH25552635 . ` I 7/1/2021 7/1/2022 IComp & Coll Deds 1,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached If more space Is required) Certificate Holder is included as Additional Insured with regard to the General and Automobile Liability per Written Contract or Agreement. SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE City of Gilroy THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ty y ACCORDANCE WITH THE POLICY PROVISIONS. 7351 Rosanna St Gilroy, CA 95020 AUTHORIZED REPRESENTATIVE ACORD 25 (2016/03) ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD POLICY NUMBER: HDO G7249099A 1 Endorsement Number: 9 COMMERCIAL GENERAL LIABILITY CG20371219 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - OWNERS, LESSEES OR CONTRACTORS - COMPLETED OPERATIONS This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE PART SCHEDULE Name Of Additional Insured Persons) Or Organizations) I Location And Descriation Of Completed Operations Any person or organization whom you have agreed to All locations where you perform work for such include as an additional insured under a written additional insured pursuant to any such written contract, provided such contract was executed prior to contract. the date of loss. I 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" 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". However: 1. The insurance afforded to such additional insured only applies to the extent permitted by law; and 2. If coverage provided to the additional insured is required by a contract or agreement, the insurance afforded to such additional insured will not be broader than that which you are required by the contract or agreement to provide for such additional insured. B. With respect to the insurance afforded to these additional insureds, the following is added to Section III — Limits Of Insurance: If coverage provided to the additional insured is required by a contract or agreement, the most we will pay on behalf of the additional insured is the amount of insurance: 1. Required by the contract or agreement; or 2. Available under the applicable limits of insurance; whichever is less. This endorsement shall not increase the applicable limits of insurance. CG 20 37 12 19 @ Insurance Services Office, Inc., 2018 Page 1 of 1 POLICY NUMBER: HDO G7249099A 1 Endorsement Number: 7 COMMERCIAL GENERAL LIABILITY CG20261219 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - DESIGNATED 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): Any person or organization whom you have agreed to include as an additional insured under a written contract, provided such contract was executed prior to the date of loss. I 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 your acts or omissions or the acts or omissions of those acting on your behalf: 1. In the performance of your ongoing operations; or 2. In connection with your premises owned by or rented to you. However: 1. The insurance afforded to such additional insured only applies to the extent permitted by law; and 2. If coverage provided to the additional insured is required by a contract or agreement, the insurance afforded to such additional insured will not be broader than that which you are required by the contract or agreement to provide for such additional insured. B. With respect to the insurance afforded to these additional insureds, the following is added to Section III — Limits Of Insurance: If coverage provided to the additional insured is required by a contract or agreement, the most we will pay on behalf of the additional insured is the amount of insurance: 1. Required by the contract or agreement; or 2. Available under the applicable limits of insurance; whichever is less. This endorsement shall not increase the applicable limits of insurance. CG 20 261219 O Insurance Services Office, Inc., 2018 Page 1 of 1 POLICY NUMBER: ISA H25552635 4 Endorsement Number: 8 COMMERCIAL AUTO CA20481013 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. DESIGNATED INSURED FOR COVERED AUTOS LIABILITY COVERAGE This endorsement modifies insurance provided under the following: AUTO DEALERS COVERAGE FORM BUSINESS AUTO COVERAGE FORM MOTOR CARRIER COVERAGE FORM With respect to coverage provided by this endorsement, the provisions of the Coverage Form apply unless modified by this endorsement. This endorsement identifies person(s) or organization(s) who are "insureds" for Covered Autos Liability Coverage under the Who Is An Insured provision of the Coverage Form. This endorsement does not alter coverage provided in the Coverage Form. This endorsement changes the policy effective on the inception date of the policy unless another date is indicated below. Named Insured: Empire Southwest, LLC Endorsement Effective Date: SCHEDULE Name Of Person(s) Or Organization(s): Information required to complete this Schedule, if not shown above, will be shown in the Declarations. Each person or organization shown in the Schedule is an "insured" for Covered Autos Liability Coverage, but only to the extent that person or organization qualifies as an "insured" under the Who Is An Insured provision contained in Paragraph A.I. of Section II — Covered Autos Liability Coverage in the Business Auto and Motor Carrier Coverage Forms and Paragraph D.2. of Section I — Covered Autos Coverages of the Auto Dealers Coverage Form. CA 20 48 10 13 © Insurance Services Office, Inc., 2011 Page 1 of 1