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ACORD® CERTIFICATE OF LIABILITY INSURANCE I DATE (MM/DD/YYYY)
<br />~-5/10/2024
<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 />PRODUCER ~~:i~cT Katie Snell
<br />lnterWest Insurance Services , LLC rr.~gN~n ~vtl • 916-609-8374 I tifc Nol : 916-609-8374 P.O . Box 8110
<br />Chico CA 95927-8110 ~~D~~ss : ksnell@iwins.com
<br />INSURER(S) AFFORDING COVERAGE NAIC#
<br />License#: 0B01094 INSURER A : Pennsylvania Mfr's Assn Ins Co 12262
<br />INSURED AMERASP -04 INSURER B : Travelers Property & Casualty Co of America 25674 American Asphalt Repair and Resurfacing Company , Inc. INSURER c : Westchester Surplus Lines Ins 10172 24200 Clawiter Rd.
<br />Hayward CA 94545 INSURER D : Arch Insurance Company 11150
<br />INSURER E :
<br />INSURER F:
<br />COVERAGES CERTIFICATE NUMBER: 681781691 REVISION NUMBER:
<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 WI T H 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 />INSR ADDL SUBR POLICY EFF POLICY EXP
<br />LTR TYPE OF INSURANCE IN!':n wvn POLICY NUMBER IMM/DD/YYYYl IMM/DD/YYYYl LIMITS
<br />A X COMMERCIAL GENERAL LIABILITY y y 3023011368497 12/31/2023 12/31/2024 EACH OCCURREN CE $1,000 ,000 -~ CLAIM S-MA DE 0 OCC UR DAMAGE TO RENTED PREMISES /Ea occurrence l $300 ,000
<br />~
<br />MED EXP (Any one pers on) $10 ,000
<br />.__ PERSONAL & ADV INJURY $1,000 ,000
<br />GEN'L AGGREGATE LI MI T APPLIES PER : GENERAL AGGREG ATE $2,000 ,000 ~ 0 PRO-□L OG PRODUCTS -COMP /OP AGG $2,000 ,000 POLIC Y JE CT
<br />OTHER: $
<br />A AUTOMOBILE LIABILITY y y 1523011368497 12/31/2023 12/31/2024 COMBINED SINGLE LIMIT $1 ,000 ,000 .__ /Ea accidentl
<br />X ANY AUTO BODILY INJURY (P er person ) $ .__ -OWNED SCHEDU LE D
<br />AUTOS ON LY AUTOS BODILY INJURY (Pe r acci de nt) $ .__ -HIRED NON-O WNE D PROPERTY DA MAGE X AUTO S ON LY X AUTOS ON LY /Per acci den t\ $
<br />$
<br />B X UMBRELLA LIAB MOCCUR CUP8T98709223 12/31/2023 12/31/2024 EACH OCCURRENCE $6,000 ,000 .__
<br />EXCESS LIAB CLAIMS-MADE AGGREGATE $6,000 ,000
<br />OED I I RETENTION $ $
<br />D WORKERS COMPENSATION y ZAWCl9413907 4/1/2024 4/1/2025 X I PER I I OTH-
<br />AND EMPLOYERS' LIABILITY STATUTE ER
<br />Y/N ANYPROPRIETOR/PAR TNER/EX ECU TIVE ~ E.L. EACH ACCIDENT $1,000 ,000 OFFICER/MEMBER EX CLUDED ? N/A
<br />(Mandatory In NH) E.L. DISEASE -EA EMP LOYEE $1,000 ,000
<br />If yes, describe unde r
<br />DESCRIPTION OF OPE RATIONS be low E.L. DISEASE -POLIC Y LIMIT $1 ,000 ,000
<br />C Pollu ti on liab ility 870915613004 8/27 /2022 8/27 /2024 LIMIT EA OCC 5,000 ,000
<br />LI MIT EA AGG 10 ,000 ,000 DEDUCTIBLE $10 ,000
<br />DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101 , Additional Remarks Schedule, may be attached if more space is required)
<br />Additional Insured status applies to requested entities , if required by written contract , per the attached policy forms/endorsements. Waiver of subrogation
<br />applies to requested entities , if required by written contract , per the attached policy forms/endorsements . Primary non-contributory applies to requested entities ,
<br />if required by written contract, per the attached policy forms/endorsements .
<br />RE : Annual Slurry Seal Project, CIP No. 24504.
<br />City of Pleasanton
<br />CERTIFICATE HOLDER CANCELLATION
<br />SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
<br />THE EXPIRATION DATE THEREOF , NOTICE WILL BE DELIVERED IN
<br />City of Pleasanton ACCORDANCE WITH THE POLICY PROVISIONS.
<br />Public Works Engineer
<br />200 Old Bernal Avenue A~UTHORIZED REPRESENTATIVE
<br />Pleasanton CA 94566
<br />.·~ I
<br />© 1988-2015 ACORD CORPORATION. All rights reserved.
<br />ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD
<br />DocuSign Envelope ID: E96A4C74-2FC7-4968-986D-B86E1F2596BA
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