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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 />7/24/2024
<br />License # 0E67768
<br />(858) 754-0063 50233 (619) 574-6288
<br />13056
<br />FCS International, Inc.
<br />250 Commerce, Suite 250
<br />Irvine, CA 92602
<br />25054
<br />A 1,000,000
<br />X PSB0008629 1/1/2024 1/1/2025 1,000,000
<br />Cont Liab/Sev of Int 10,000
<br />1,000,000
<br />2,000,000
<br />2,000,000
<br />Ded 0
<br />1,000,000A
<br />PSA0002832 1/1/2024 1/1/2025
<br />No Co. Owned
<br />Autos
<br />5,000,000A
<br />PSE0004283 1/1/2024 1/1/2025 5,000,000
<br />0
<br />A
<br />X PSW0004799 1/1/2024 1/1/2025 1,000,000
<br />Y 1,000,000
<br />1,000,000
<br />B Professional Liab.PRB0619117942 1/1/2024 Per Claim 2,000,000
<br />B Professional Liabili PRB0619117942 1/1/2024 1/1/2025 Aggregate 2,000,000
<br />Re: on-call contract
<br />The City of Pleasanton, its officers, employees and agents are Additional Insureds with respect to General Liability per the attached endorsement as required
<br />by written contract. Insurance is Primary and Non-Contributory. Waiver of Subrogation applies to Workers' Compensation.
<br />30 Days Notice of Cancellation with 10 Days Notice for Non-Payment of Premium in accordance with the policy provisions.
<br />City of Pleasanton
<br />P.O. Box 520
<br />Pleasanton, CA 94566
<br />FCSINTE-01 MCCOWANA
<br />IOA Insurance Services
<br />3636 Nobel Drive
<br />Suite 410
<br />San Diego, CA 92122
<br />Erica Wilson
<br />Erica.Wilson@ioausa.com
<br />RLI Insurance Company
<br />Hudson Insurance Company
<br />X
<br />1/1/2025
<br />X
<br />X
<br />X
<br />X
<br />X
<br />X
<br />X
<br />X
<br />X
<br />X
<br />Docusign Envelope ID: D52ECD8B-B3AB-4975-A815-510A15A4FE73
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