|
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 $(Ea accident)
<br />ANY AUTO BODILY INJURY (Per person) $
<br />OWNED SCHEDULED
<br />BODILY INJURY (Per accident) $AUTOS ONLY AUTOS
<br />HIRED NON-OWNED
<br />PROPERTY DAMAGE $AUTOS ONLY AUTOS ONLY
<br />(Per accident)
<br />$
<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 />6/5/2024
<br />License # 0C41366
<br />(925) 462-8400 (925) 462-8888
<br />25674
<br />4LEAF, Inc.
<br />2126 Rheem Dr
<br />Pleasanton, CA 94588
<br />20044
<br />42374
<br />A 1,000,000
<br />X 6806X631656 3/15/2024 3/15/2025
<br />1,000,000
<br />5,000
<br />1,000,000
<br />2,000,000
<br />2,000,000
<br />1,000,000A
<br />8106X632782 3/15/2024 3/15/2025
<br />6,000,000A
<br />CUP6X635599 3/15/2024 3/15/2025 6,000,000
<br />B
<br />X FOWC521971 3/15/2024 3/15/2025 1,000,000
<br />1,000,000
<br />1,000,000
<br />C Professional Liab HCC2425616 4/9/2024 Each Claim 2,000,000
<br />C HCC2425616 4/9/2024 3/15/2025 Aggregate 2,000,000
<br />The attached forms apply as required per written contract or written agreements between the listed parties and the insured, which are subject to the policy
<br />provisions. In the absence of such written contract or written agreement the attached form may not be applicable.
<br />City, its officers, employees and agents are named as Additional Insureds to General Liability policy per the attached endorsement CG D3 81 09 15. Primary
<br />and non-contributory applies to General Liability policy per attached endorsement CG D3 81 09 15. Waiver of Subrogation applies to Workers Compensation
<br />policy per attached endorsement WC 99 04 10 C.
<br />City of Pleasanton
<br />P.O. Box 520
<br />Pleasanton, CA 94566
<br />4LEAINC-01 MINED1
<br />Granite Professional Insurance Brokerage, Inc.
<br />360 Lindbergh Avenue
<br />Livermore, CA 94551 commercial@graniteins.com
<br />Travelers Property Casualty Company of America
<br />Berkshire Hathaway Homestate
<br />Houston Casualty Company
<br />X
<br />3/15/2025
<br />X
<br />X
<br />X
<br />X
<br />X X
<br />X X
<br />DocuSign Envelope ID: 27E79A54-51B9-4F19-98C5-1BA1910A416B
|