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Docusign Envelope ID: 561334F4-4433-43FE-A104-OE7BB8C651 F2
<br />71,6/28/2024
<br />,acoRo° CERTIFICATE DATE LIABILITY INSURANCE (MM/DD/YYYY)
<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 CONTACT
<br />Kell Philli s
<br />NAME:
<br />Edgewood Partners Insurance Center FAX PHONE
<br />,
<br />P.O. Box 2110 C No EM : 916-358-8024 (A/C.
<br />A/c No): 916-583-7613
<br />Rancho Cordova CA 95670 ADDRESS: [email protected]
<br />License#: OB29370
<br />INSURER A:
<br />BETA Healthcare Group
<br />99900
<br />INSURED
<br />AXISCOMM
<br />INSURERB:
<br />Federal Insurance Company
<br />20281
<br />Axis Community Health, Inc.
<br />5925 West Las Positas Blvd Suite 100
<br />INSURERC:
<br />Federal Insurance Company
<br />20281
<br />Pleasanton CA 94588
<br />INSURERD:
<br />Beazley Insurance Company, Inc.
<br />37540
<br />INSURER E :
<br />INSURER F :
<br />COVERAGES CERTIFICATE NUMBER: 1904740737
<br />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 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 />INSR
<br />LTR
<br />TYPE OF INSURANCE
<br />ADDL
<br />SUBR
<br />NUMBER
<br />PICPOLICY
<br />MM DDY/YYYY
<br />EXP
<br />MM DDY/YYYY
<br />LIMITS
<br />A
<br />X
<br />COMMERCIAL GENERAL LIABILITY
<br />HCL241064
<br />7/1/2024
<br />7/1/2025
<br />EACH OCCURRENCE
<br />$4,000,000
<br />CLAIMS -MADE � OCCUR
<br />DAMAGES( RENTED
<br />PREMISES Ea occurrence)
<br />$ 500,000
<br />MED EXP (Any one person)
<br />$ 5,000
<br />PERSONAL & ADV INJURY
<br />$5,000,000
<br />GEN'L AGGREGATE LIMIT APPLIES PER:
<br />GENERAL AGGREGATE
<br />$ 5,000,000
<br />POLICY PRO LOC
<br />X JECT
<br />F—I$
<br />PRODUCTS - COMP/OP AGG
<br />$ Included
<br />OTHER:
<br />B
<br />AUTOMOBILE
<br />LIABILITY
<br />73609883
<br />7/1/2024
<br />7/1/2025
<br />COMBINED SINGLE LIMIT
<br />Ea accident
<br />$1,000,000
<br />BODILY INJURY (Per person)
<br />$
<br />ANY AUTO
<br />OWNED SCHEDULED
<br />AUTOS ONLY AUTOS
<br />BODILY INJURY (Per accident)
<br />$
<br />X
<br />PROPERTY DAMAGE
<br />Per accident
<br />$
<br />HIRED Ix NON -OWNED
<br />AUTOS ONLY AUTOS ONLY
<br />UMBRELLA LIAB
<br />OCCUR
<br />EACH OCCURRENCE
<br />$
<br />AGGREGATE
<br />$
<br />EXCESS LIAB
<br />CLAIMS -MADE
<br />DED RETENTION $
<br />$
<br />A
<br />WORKERS COMPENSATION
<br />AND EMPLOYERS' LIABILITY Y / N
<br />WC241064
<br />7/1/2024
<br />7/1/2025
<br />X PER OTH-
<br />STATUTE ER
<br />ANYPROPRIETOR/PARTNER/EXECUTIVE
<br />E.L. EACH ACCIDENT
<br />$ 2,000,000
<br />OFFICER/MEMBEREXCLUDED? ❑
<br />N/A
<br />E.L. DISEASE - EA EMPLOYEE
<br />$ 2,000,000
<br />(Mandatory in NH)
<br />If yes, describe under
<br />DESCRIPTION OF OPERATIONS below
<br />E.L. DISEASE - POLICY LIMIT
<br />$ 2,000,000
<br />C
<br />Crime - Employee Theft
<br />82553413
<br />7/1/2024
<br />7/1/2025
<br />Limit: $400,000
<br />Retention: $2,000
<br />A
<br />D
<br />Professional Liability RD 5/01/77
<br />Cyber Liability
<br />HCL241064
<br />W32E2A230201
<br />7/1/2024
<br />7/1/2023
<br />7/1/2025
<br />7/1/2024
<br />Each Claim $4,000,000
<br />Aggregate
<br />Agg: $5,000,000
<br />2,000,000
<br />DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required)
<br />Excess Worker's Compensation, Carrier: Safety National Casualty Corporation, NAIC #15105, Policy #SP4066651, Term: 07/01/24-07/01/25, Statutory Limits
<br />Excess of $1,000,000.
<br />Re: All Contracts/Written Agreements between the Certificate Holder and the Insured. Additional Insured: City of Pleasanton, its officials, employees, agents
<br />and volunteers. When required by written contract, additional insured status with primary coverage and waiver of subrogation apply to General Liability and
<br />Workers' Compensation, all per the attached endorsements.
<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, its officials, employees, agents and
<br />ACCORDANCE WITH THE POLICY PROVISIONS.
<br />volunteers
<br />AUTHORIZED REPRESENTATIVE
<br />PO Box 520
<br />Pleasanton CA 94566
<br />©1988-2015 ACORD CORPORATION. All rights reserved.
<br />ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD
<br />
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