|
ANY PROPRIETOR/PARTNER/EXECUTIVE
<br />OFFICER/MEMBER EXCLUDED?
<br />INSR ADDL SUBR
<br />LTR INSD WVD
<br />PRODUCER CONTACT
<br />NAME:
<br />FAXPHONE
<br />(A/C, No):(A/C, No, Ext):
<br />E-MAIL
<br />ADDRESS:
<br />INSURER A :
<br />INSURED INSURER B :
<br />INSURER C :
<br />INSURER D :
<br />INSURER E :
<br />INSURER F :
<br />POLICY NUMBER POLICY EFF POLICY EXPTYPE OF INSURANCE LIMITS(MM/DD/YYYY)(MM/DD/YYYY)
<br />AUTOMOBILE LIABILITY
<br />UMBRELLA LIAB
<br />EXCESS LIAB
<br />WORKERS COMPENSATION
<br />AND EMPLOYERS' LIABILITY
<br />DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required)
<br />AUTHORIZED REPRESENTATIVE
<br />EACH OCCURRENCE $
<br />DAMAGE TO RENTEDCLAIMS-MADE OCCUR $PREMISES (Ea occurrence)
<br />MED EXP (Any one person)$
<br />PERSONAL & ADV INJURY $
<br />GEN'L AGGREGATE LIMIT APPLIES PER:GENERAL AGGREGATE $
<br />PRO-POLICY LOC PRODUCTS - COMP/OP AGGJECT
<br />OTHER:$
<br />COMBINED SINGLE LIMIT
<br />$(Ea accident)
<br />ANY AUTO BODILY INJURY (Per person)$
<br />OWNED SCHEDULED
<br />BODILY INJURY (Per accident)$AUTOS ONLY AUTOS
<br />HIRED NON-OWNED PROPERTY DAMAGE
<br />$AUTOS ONLY AUTOS ONLY (Per accident)
<br />$
<br />OCCUR EACH OCCURRENCE
<br />CLAIMS-MADE AGGREGATE $
<br />DED RETENTION $
<br />PER OTH-
<br />STATUTE ER
<br />E.L. EACH ACCIDENT
<br />E.L. DISEASE - EA EMPLOYEE $
<br />If yes, describe under
<br />E.L. DISEASE - POLICY LIMITDESCRIPTION OF OPERATIONS below
<br />INSURER(S) AFFORDING COVERAGE NAIC #
<br />COMMERCIAL GENERAL LIABILITY
<br />Y / N
<br />N / A
<br />(Mandatory in NH)
<br />SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
<br />THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
<br />ACCORDANCE WITH THE POLICY PROVISIONS.
<br />THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
<br />INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
<br />CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,
<br />EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
<br />THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS
<br />CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
<br />BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED
<br />REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER.
<br />IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must have ADDITIONAL INSURED provisions or be endorsed.
<br />If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on
<br />this certificate does not confer rights to the certificate holder in lieu of such endorsement(s).
<br />COVERAGES CERTIFICATE NUMBER:REVISION NUMBER:
<br />CERTIFICATE HOLDER CANCELLATION
<br />© 1988-2015 ACORD CORPORATION. All rights reserved.ACORD 25 (2016/03)
<br />CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DD/YYYY)
<br />$
<br />$
<br />$
<br />$
<br />$
<br />The ACORD name and logo are registered marks of ACORD
<br />7/18/2023
<br />License # 0757776
<br />(877) 825-2681 (951) 231-2572
<br />25674
<br />Associated Right of Way Services, Inc.
<br />1255 Treat Blvd., Suite 815
<br />Walnut Creek, CA 94597
<br />25682
<br />34630
<br />42374
<br />A 2,000,000
<br />X X 680-3N941028-23-47 7/17/2023 7/17/2024 1,000,000
<br />Deductible - $0 5,000
<br />2,000,000
<br />4,000,000
<br />4,000,000
<br />PROJECT AND LOC 4,000,000
<br />1,000,000B
<br />X BA-9R375286-23-47-G 7/17/2023 7/17/2024
<br />Deductible 0
<br />2,000,000A
<br />CUP-3N942523-23-47 7/17/2023 7/17/2024 2,000,000
<br />C
<br />X ASWC449563 1/10/2023 1/10/2024 1,000,000
<br />N 1,000,000
<br />1,000,000
<br />D Errors & Omissions H7231-21722 7/17/2023 Per Claim 2,000,000
<br />D Errors & Omissions H7231-21722 7/17/2023 7/17/2024 Aggregate 2,000,000
<br />**Deductibles for each policy | General Liability-$0 | Auto Liability-$0 | Umbrella Liability-$0 | Workers Compensation-$0 | Professional Liability-$10,000**
<br />*Umbrella goes over the following policies only: 680-3N941028-23-47, BA-9R375286-23-47-G, ASWC449563*
<br />RE: Reference: Right of Way Services – Lemoine Bypass Pipeline Project.
<br />City of Pleasanton, its officers, employees and agents are Additional Insured with regard to General Liability when required by written contract per the
<br />attached endorsement form CGD381 09/15, Primary & Non -Contributory and Waiver of Subrogation included. Additional Insured with regard to Auto Liability
<br />when required by written contract per the attached endorsement form CAT420 02/15. Waiver of Subrogation with regard to Workers Compensation applies
<br />SEE ATTACHED ACORD 101
<br />City of Pleasanton
<br />City Manager
<br />P.O. Box 520
<br />Pleasanton, CA 94566
<br />ASSORIG-01 KCHANDRA
<br />HUB International Insurance Services Inc.
<br />1525 Faraday Avenue
<br />Suite 150
<br />Carlsbad, CA 92008
<br />Mayra Murillo
<br />cal.cpu@hubinternational.com
<br />Travelers Property Casualty Company of America
<br />The Travelers Indemnity Company of Connecticut
<br />Oak River Insurance Company
<br />Houston Casualty Company
<br />X
<br />7/17/2024
<br />X
<br />X
<br />X
<br />X
<br />X
<br />X X
<br />DocuSign Envelope ID: 6A6C77F6-39E6-41AA-9B50-294D6C899487
|