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DATE (MM/DD/YYYY)
CERTIFICATE OF LIABILITY INSURANCE 12/29/2021
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 Willis Topers Watson Certificate Center
NAME:
Willis Towers Watson Northeast, Inc. PHONE 1-877-945-7378 FAX 1-888-467-2378
c/o 26 Century Blvd Ex 14 A/C No
P.O. Box 305191 ADDRESS: certificates@willis.com
Nashville, TN 372305191 USA INSURERS AFFORDING COVERAGE NAIC 4
INSURED
Sammons Transportation, Inc dba DSV Road Transport, Inc.
7211 Two smokes Way
P.O. Box 16050
Missoula, EST 59808
INSURER A : XL Insurance America Inc 24554
INSURER B : ACE American Insurance Company 22667
INSURER C : Indemnity Insurance Company of North Ameri' 43575
INSURER D : National Union Fire Insurance Company of P I 19445
INSURER E :
MIMI roLo c .
COVERAGES CERTIFICATE NLIMBER- W23561360 RFVI-glnN NUMRER-
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.
LTR I TYPE OF INSURANCE POLICY NUMBER
MM/DD/YYY MM/DD/YYYY LIMITS
X COMMERCIAL GENERAL LIABILITY
! EACH OCCURRENCE $
2,000,000
CLAIMS -MADE i X OCCUR
DAMAGE TO RENTED
PREMISE6_(Ea ocwrrence '_$
2,000,000
A
MED EXP (Any one person) j $
5,000
Y US00096086LI22A
01/01/2022
01/01/2023 PERSONAL 6 ADV INJURY i, $
2,000,000
GEN'L AGGREGATE LIMIT APPLIES PER:
GENERAL AGGREGATE, $
4,000,000
PRO•
POLICY � JEC7 x LOC
� �
_ ��----------- --- � $
' PRODUCTS - COMP/OP AGG —_ -_
4,000,000
i OTHER:
is
AUTOMOBILE LIABILITY
COMBINED SINGLE LIMIT $
(Ea accident).-___
2, 000,000
X ANY AUTO
BODILY INJURY (Per person) $
B
OWNED SCHEDULED Y MMT M25552489
AUTOS ONLY AUTOS
NON
22/32/2021
12/31/2022 ; BODILY INJURY (Per accident)', $
HIRED -OWNED
AUTOS ONLY � AUTOS ONLY
PROPERTY DAMAGE
Per accident f
$
UMBRELLA LIAR OCCUR
EACH OCCURRENCE is
EXCESS LIAB CLAIMS -MADE
AGGREGATE $
DED { RETENTION $
Is
WORKERS COMPENSATION
PER H-
X i STATUTE 1 ER
AND EMPLOYERS' LIABILITY Y/ N
C
XECUTIVENo
OFICRiMEMBEREXCLUDEDN/A WLR C67823311
12/31/2021
E.L. EACH ACCIDENT $
12/31/2022`(Mandato
2,000,000
In NH)
E.L. DISEASE - EA EMPLOYEE $
2,000,000
It es, describe under
DACRIPTION OF OPERATIONS below
E.L. DISEASE - POLICY LIMIT 1 $
2,000,000
D Cargo Legal Liability 02-543-70-86
01/01/2022
01/01/2023iLimit of Insurance
�$200,000
DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required)
Workers Compensation Includes USL&H and Maritime Coverage
Certificate Holder is named as an additional insured as their
interests may appear with respects to General and Auto
Liability coverage.
CFRTIFICOTF i4ni nr-P f_eNCFI I OTIAN
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
CITY OF GILROY
AUTHORIZED REPRESENTATIVE
7351 ROSANNA ST
I
GILROY, CA 95020
01988-2016 ACORD CORPORATION. All rights reserved.
ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD
3R ID: 22003784 BATCH: 2353946
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