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HomeMy WebLinkAboutCOI - Adams Ashby Group Inc. - Expires 2024-06-01CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DD/YYYY) 10/23/2023 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 be endorsed.If SUBROGATIONIS 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 USAA INSURANCE AGENCY INC/PHS 65812846 The Hartford Business Service Center 3600 Wiseman Blvd San Antonio, TX 78251 CONTACT NAME: PHONE (A/C, No, Ext): (866) 467-8730 FAX (A/C, No): E-MAIL ADDRESS: INSURER(S) AFFORDING COVERAGE NAIC# INSURED ADAMS ASHBY GROUP INC. 1000 LINCOLN RD # H212 YUBA CITY CA 95991-6598 INSURER A : Sentinel Insurance Company Ltd.11000 INSURER B : Continental Casualty Co. INSURER C : INSURER D : INSURER E : INSURER F : COVERAGES CERTIFICATE NUMBER: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 INSR SUBR WVD POLICY NUMBER POLICY EFF (MM/DD/YYYY) POLICY EXP (MM/DD/Y YYY)LIMITS A COMMERCIAL GENERAL LIABILITY X 65 SBA NW6130 06/01/2023 06/01/2024 EACH OCCURRENCE $2,000,000 CLAIMS-MADE X OCCUR DAMAGE TO RENTED PREMISES (Ea occurrence)$1,000,000 X General Liability MED EXP (Any one person)$10,000 PERSONAL & ADV INJURY $2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER:GENERAL AGGREGATE $4,000,000 POLICY PRO- JECT X LOC PRODUCTS - COMP/OP AGG $4,000,000 OTHER: A AUTOMOBILE LIABILITY 65 SBA NW6130 06/01/2023 06/01/2024 COMBINED SINGLE LIMIT (Ea accident)$2,000,000 ANY AUTO BODILY INJURY (Per person) ALL OWNED AUTOS SCHEDULED AUTOS BODILY INJURY (Per accident) X HIRED AUTOS X NON-OWNED AUTOS PROPERTY DAMAGE (Per accident) UMBRELLA LIAB EXCESS LIAB OCCUR CLAIMS- MADE EACH OCCURRENCE AGGREGATE DED RETENTION $ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below N/ A PER STATUTE OTH- ER Y/N E.L. EACH ACCIDENT E.L. DISEASE -EA EMPLOYEE E.L. DISEASE - POLICY LIMIT Professional Liability 596466820 05/19/2023 05/19/2024 Each Occurrence Aggregate $1,000,000 $2,000,000 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) Those usual to the Insured's Operations. The City of Gilroy, its officers, officials, and employees are named as additional insureds are additional insured per the Business Liability Coverage Form SS0008 attached to this policy. Certificate Holder is an additional insured per the Professional Liability Coverage when required by contract. CERTIFICATE HOLDER CANCELLATION City of Gilroy 7351 ROSANNA ST GILROY CA 95020-6141 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 DocuSign Envelope ID: A8574B63-AB93-4413-BDD2-B7ED72319326 3600 WISEMAN BLVD. SAN ANTONIO TX 78251 (888)242-1430 (888)242-1430 SERVICE.TX@THEHARTFORD.COM (888)242-1430 (888)242-1430 USAA INSURANCE AGENCY INC/PHS The Hartford Hartford Fire Insurance Company and its Affiliates One Hartford Plaza,Hartford,Connecticut 06155 001 (CONTINUED ON NEXT PAGE) 05/25/23 06/01/23 06/01/24 65 SBA NW6130 DX ADAMS ASHBY GROUP,INC SEE FORM SS1235 1000 LINCOLN RD H212 YUBA CITY CA 95991 06/01/23 001 USAA INSURANCE AGENCY INC/PHS 812846 SENTINEL INSURANCE COMPANY,LIMITED ANY CHANGES IN YOUR PREMIUM WILL BE REFLECTED IN YOUR NEXT BILLING STATEMENT.IF YOU ARE ENROLLED IN REPETITIVE EFT DRAWS FROM YOUR BANK ACCOUNT,CHANGES IN PREMIUM WILL CHANGE FUTURE DRAW AMOUNTS. THIS IS NOT A BILL. ADDITIONAL PREMIUM DUE AT POLICY CHANGE EFFECTIVE DATE:$18.00 *INCLUDES ADDITIONAL TERRORISM PREMIUM OF:$1.00 LOCATION 001 BUILDING 001 IS REVISED PRO RATA FACTOR:1.000 THIS ENDORSEMENT DOES NOT CHANGE THE POLICY EXCEPT AS SHOWN. Form SS 12 11 04 05 T Page Process Date:Policy Effective Date: Policy Expiration Date: 002 05/25/23 06/01/23 06/01/24 65 SBA NW6130 001 PROPERTY OPTIONAL COVERAGES APPLICABLE TO ALL LOCATIONS ARE ADDED COMPUTERS AND MEDIA COVERAGE FORM SS 04 41 DEDUCTIBLE:$1,000 BUSINESS LIABILITY OPTIONAL COVERAGES ARE REVISED WAIVER OF SUBROGATION IS ADDED:FORM SS 12 15 LOCATION 001 BUILDING 001 SEE FORM IH 12 00 FORM NUMBERS OF ENDORSEMENTS REVISED AT ENDORSEMENT ISSUE: IH12001185 ADDITIONAL INSURED -PERSON-ORGANIZATION FORM NUMBERS OF ENDORSEMENTS ADDED AT ENDORSEMENT ISSUE: SS 12 15 03 00 IH12001185 WAIVER OF SUBROGATION Form SS 12 11 04 05 T Page Process Date:Policy Effective Date: Policy Expiration Date: POLICY CHANGE (Continued) Policy Number: Policy Change Number: DocuSign Envelope ID: A8574B63-AB93-4413-BDD2-B7ED72319326 65 SBA NW6130 ADDITIONAL INSURED -PERSON-ORGANIZATION COMMUNITY DEVELOPMENT COMMISSION OF THE CITY OF ROHNERT PARK 130 AVRAM AVE. ROHNERT PART,CA 94928 CITY OF TRACY INCLUDING ITS ELECTED OFFICIALS,OFFICERS,EMPLOYEES, AGENTS AND VOLUNTEERS 333 CIVIC CENTER PLAZA TRACY CA 95376 COUNTY OF TEHANA IT'S ELECTIVE OFFICIALS,OFFICERS,EMPLOYEES AND VOLUNTEERS 727 OAK STREET RED BLUFF,CA 96080 COUNTY OF YOLO 625 COURT ST STE 202 WOODLAND,CA 95695 VALLEY CONTRACTORS EXCHANGE 951 EAST 8TH ST. CHICO,CA.95928 COUNTY OF NEVADA,AND ITS OFFICERS,AGENTS,EMPLOYEES &VOLUNTEERS 950 MAIDU AVE NEVADA CITY,CA 95959 RE:LOC 001 &002 BLDGS 001 CALAVERAS HEALTH AND HUMAN SERVICES AGENCY ATTENTION:MARK KSENZULAK 509 EAST ST.CHARLES STREET SAN ANDREAS,CA 95249 003 001 (CONTINUED ON NEXT PAGE) 05/25/23 06/01/24 65 SBA NW6130 ADDITIONAL INSURED -PERSON-ORGANIZATION CITY OF GILROY ITS OFFICERS,OFFICIALS AND EMPLOYEES 7351 ROSANNA ST GILROY,CA 95020 THE CITY OF FORT BRAGG,ITS OFFICIALS,OFFICERS,EMPLOYEES,AGENTS, AND VOLUNTEERS 416 N FRANKLIN STREET FORT BRAGG,CA 95437 CITY OF ANGELS CAMP PO BOX 667 ANGELS CAMP CA 95222-0667 CITY OF YREKA 701 4TH ST YREKA,CA 96097 CITY OF MANTECA 1001 W CENTER ST MANTECA,CA 95337 COUNTY OF NEVADA -HHSA, 950 MAIDU AVE NEVADA CITY,CA 95959-7902 003 002 (CONTINUED ON NEXT PAGE) 05/25/23 06/01/24 65 SBA NW6130 ADDITIONAL INSURED -PERSON-ORGANIZATION 003 003 (CONTINUED ON NEXT PAGE) 05/25/23 06/01/24 65 SBA NW6130 WAIVER OF SUBROGATION COUNTY OF NEVADA -HHSA, 950 MAIDU AVE NEVADA CITY,CA 95959-7902 005 001 (CONTINUED ON NEXT PAGE) 05/25/23 06/01/24 3600 WISEMAN BLVD. SAN ANTONIO TX 78251 (888)242-1430 (888)242-1430 SERVICE.TX@THEHARTFORD.COM (888)242-1430 (888)242-1430 USAA INSURANCE AGENCY INC/PHS The Hartford Hartford Fire Insurance Company and its Affiliates One Hartford Plaza,Hartford,Connecticut 06155 001 (CONTINUED ON NEXT PAGE) 05/25/23 06/01/22 06/01/23 65 SBA NW6130 DX ADAMS ASHBY GROUP,INC SEE FORM SS1235 1000 LINCOLN RD H212 YUBA CITY CA 95991 05/25/23 005 USAA INSURANCE AGENCY INC/PHS 812846 SENTINEL INSURANCE COMPANY,LIMITED ANY CHANGES IN YOUR PREMIUM WILL BE REFLECTED IN YOUR NEXT BILLING STATEMENT.IF YOU ARE ENROLLED IN REPETITIVE EFT DRAWS FROM YOUR BANK ACCOUNT,CHANGES IN PREMIUM WILL CHANGE FUTURE DRAW AMOUNTS. THIS IS NOT A BILL. NO PREMIUM DUE AS OF POLICY CHANGE EFFECTIVE DATE LOCATION 002 BUILDING 001 IS REVISED PRO RATA FACTOR:0.019 THIS ENDORSEMENT DOES NOT CHANGE THE POLICY EXCEPT AS SHOWN. Form SS 12 11 04 05 T Page Process Date:Policy Effective Date: Policy Expiration Date: 002 05/25/23 06/01/22 06/01/23 65 SBA NW6130 005 PROPERTY OPTIONAL COVERAGES APPLICABLE TO ALL LOCATIONS ARE ADDED COMPUTERS AND MEDIA COVERAGE FORM SS 04 41 DEDUCTIBLE:$1,000 BUSINESS LIABILITY OPTIONAL COVERAGES ARE REVISED WAIVER OF SUBROGATION IS ADDED:FORM SS 12 15 LOCATION 002 BUILDING 001 SEE FORM IH 12 00 FORM NUMBERS OF ENDORSEMENTS REVISED AT ENDORSEMENT ISSUE: IH12001185 ADDITIONAL INSURED -PERSON-ORGANIZATION FORM NUMBERS OF ENDORSEMENTS ADDED AT ENDORSEMENT ISSUE: SS 12 15 03 00 IH12001185 WAIVER OF SUBROGATION Form SS 12 11 04 05 T Page Process Date:Policy Effective Date: Policy Expiration Date: POLICY CHANGE (Continued) Policy Number: Policy Change Number: DocuSign Envelope ID: A8574B63-AB93-4413-BDD2-B7ED72319326 65 SBA NW6130 ADDITIONAL INSURED -PERSON-ORGANIZATION COMMUNITY DEVELOPMENT COMMISSION OF THE CITY OF ROHNERT PARK 130 AVRAM AVE. ROHNERT PART,CA 94928 CITY OF TRACY INCLUDING ITS ELECTED OFFICIALS,OFFICERS,EMPLOYEES, AGENTS AND VOLUNTEERS 333 CIVIC CENTER PLAZA TRACY CA 95376 COUNTY OF TEHANA IT'S ELECTIVE OFFICIALS,OFFICERS,EMPLOYEES AND VOLUNTEERS 727 OAK STREET RED BLUFF,CA 96080 COUNTY OF YOLO 625 COURT ST STE 202 WOODLAND,CA 95695 VALLEY CONTRACTORS EXCHANGE 951 EAST 8TH ST. CHICO,CA.95928 COUNTY OF NEVADA,AND ITS OFFICERS,AGENTS,EMPLOYEES &VOLUNTEERS 950 MAIDU AVE NEVADA CITY,CA 95959 RE:LOC 001 &002 BLDGS 001 CALAVERAS HEALTH AND HUMAN SERVICES AGENCY ATTENTION:MARK KSENZULAK 509 EAST ST.CHARLES STREET SAN ANDREAS,CA 95249 003 001 (CONTINUED ON NEXT PAGE) 05/25/23 06/01/23 65 SBA NW6130 ADDITIONAL INSURED -PERSON-ORGANIZATION CITY OF GILROY ITS OFFICERS,OFFICIALS AND EMPLOYEES 7351 ROSANNA ST GILROY,CA 95020 THE CITY OF FORT BRAGG,ITS OFFICIALS,OFFICERS,EMPLOYEES,AGENTS, AND VOLUNTEERS 416 N FRANKLIN STREET FORT BRAGG,CA 95437 CITY OF ANGELS CAMP PO BOX 667 ANGELS CAMP CA 95222-0667 CITY OF YREKA 701 4TH ST YREKA,CA 96097 CITY OF MANTECA 1001 W CENTER ST MANTECA,CA 95337 COUNTY OF NEVADA -HHSA, 950 MAIDU AVE NEVADA CITY,CA 95959-7902 003 002 (CONTINUED ON NEXT PAGE) 05/25/23 06/01/23 65 SBA NW6130 WAIVER OF SUBROGATION COUNTY OF NEVADA -HHSA, 950 MAIDU AVE NEVADA CITY,CA 95959-7902 005 001 (CONTINUED ON NEXT PAGE) 05/25/23 06/01/23 1001486 2005 155279 205 01-19-2023 INSR LTR TYPE OF INSURANCE ADD INSD SUB WVD POLICY NUMBER POLICY EFF (MM/DD/YYYY)POLICY EXP (MM/DD/YYYY)LIMITS COMMERCIAL GENERAL LIABILITY CLAIMS-MADE OCCUR GEN'L AGGREGATE LIMIT APPLIES PER: POLICY PRO- JECT LOC OTHER: EACH OCCURRENCE $ DAMAGE TO RENTED PREMISES (Ea occurrence)$ MED EXP (Any one person)$ PERSONAL & ADV INJURY $ GENERAL AGGREGATE $ PRODUCTS - COMP/OP AGG $ $ AUTOMOBILE LIABILITY ANY AUTO OWNED AUTOS ONLY SCHEDULED AUTOSHIRED AUTOS ONLY NON-OWNED AUTOS ONLY COMBINED SINGLE LIMIT (Ea accident)$ BODILY INJURY (Per person)$ BODILY INJURY (Per accident)$ PROPERTY DAMAGE (Per accident)$ $ UMBRELLA LIAB OCCUR EXCESS LIAB CLAIMS-MADE DED RETENTION $ EACH OCCURRENCE $ AGGREGATE $ $ A WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below N Y / N N / A N 90-GB-R313-3 04/04/2023 04/04/2024 PER STATUTE OTH- ER $ E.L. EACH ACCIDENT 1,000,000$ E.L. DISEASE - EA EMPLOYEE 1,000,000$ E.L. DISEASE - POLICY LIMIT 1,000,000$ SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. CANCELLATION AUTHORIZED REPRESENTATIVE 11/06/2023This form was system-generated on . E-MAIL ADDRESS:jeff.draper.gah7@statefarm.com CONTACT NAME:Jeff Draper PHONE (A/C, No, Ext):530-846-2749 FAX (A/C, No): INSURER(S) AFFORDING COVERAGE NAIC # INSURER A :State Farm Fire and Casualty Company 25143 INSURER B : INSURER C : INSURER D : INSURER E : INSURER F : PRODUCER INSURED Jeff Draper 300 Spruce Street Suite B Gridley CA 959482218 ADAMS ASHBY GROUP INC 1000 LINCOLN RD STE H STE 212 YUBA CITY CA 959916598 REVISION NUMBER:CERTIFICATE NUMBER:COVERAGES 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). 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. 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. DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DD/YYYY) 11/06/2023 ACORD 25 (2016/03) © 1988-2015 ACORD CORPORATION. All rights reserved. CERTIFICATE HOLDER City Of Gilroy 7351 Rosanna Street Gilroy CA 95020 The ACORD name and logo are registered marks of ACORD DocuSign Envelope ID: A8574B63-AB93-4413-BDD2-B7ED72319326