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ACORD® CERTIFICATE OF LIABILITY INSURANCE I
<br />DATE (MM/DD/YYYY)
<br />~ 08/28/2024
<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($), 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 Bill Ayers Crescenta Valley Insurance NAME:
<br />PHONE (818) 439-2360 I rffc Nol: (818) 248-3348 3156 Foothill Blvd. Ste A /Alt" Nn i::vtl•
<br />E-MAIL bill@cvlns.com La Crescenta, CA 91214 ADDRESS :
<br />License #: 0C91996 INSURER(Sl AFFORDING COVERAGE NAIC#
<br />INSURER A: Mt. Hawley Insurance Company 37974
<br />INSURED INSURERB: State Farm Mutual Automobile Insurance Co 25178
<br />lntegra Construction Services, Inc. INSURERC: State Compensation Insurance Fund 35076
<br />4133 - D Mohr Ave. INSURER D: lronshore Specialty Insurance Comoanv 25445
<br />Pleasanton, CA 94566 INSURER E :
<br />INSURER F :
<br />COVERAGES CERTIFICATE NUMBER: 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 ADDL SUBR POLICYEFF POLICY EXP
<br />LTR TYPE OF INSURANCE INC:n wvn POLICY NUMBER IMM/DD/YYYYl IMM/DD/YYYYl LIMITS
<br />A _x_ COMMERCIAL GENERAL LIABILITY y y MGL0198215 01/20/2024 01/20/2025 EACH OCCURRENCE $ 1,000,000 D CLAIMS-MADE [x] OCCUR
<br />DAMAGE TO REN TED 50,000 PREM ISE S /Ea occurrence\ $
<br />-MED EXP (Any one person) $ 5,000
<br />PERSONAL & ADV INJURY -$ 1,000,000
<br />GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000
<br />~ □PRO-D Loc PRODUCTS -COMP/OP AGG $ 2,000,000 POLICY JECT
<br />OTHER: $
<br />B AUTOMOBILE LIABILITY 4 72-67 40-B09-058 08/09/2024 08/09/2025 COMBINED SINGLE LIMIT $ 2,000,000 /Ea accidentl x ANY AUTO BOD ILY IN JURY (Per person) $ 2,000,000 x OWNED ~X SCHEDULED BODILY INJURY (Per accident) $ 2 000.000 AUTOS ONLY ..,.._ AU TOS x HIRED X NON-OWNED PROPERTY DAMAGE $ 2,000,000 AUTOS ONLY ..,.._ AUTOSONLY /Per accident\ -$
<br />A UMBRELLA LIAB
<br />~
<br />OCCUR y y MXL0439063 01/20/2024 01/20/2025 EACH OCCURRENCE $ 3,000,000 -X EXCESS LIAB CLAIMS-MAD E AGGREGATE $ 3,000,000
<br />DED I I RETENTION $ Products -Comp $ 3,000,000
<br />C WORKERS COMPENSATION 1920674-24 06/01/2024 X I ~~fTUTE I I OTH-
<br />AND EMPLOYERS' LIABILITY 06/01/2025 ER
<br />Y/N 1,000,000 ANY PROPRIETOR/PARTNER/EXECUTIVE [yJ E.L. EACH ACCIDENT $
<br />OFFICER/M EMBE R EXC LUDED? N/A 1,000,000 (Mandatory In NH) E.L. DISEASE -EA EMPLOYEE $
<br />If yes , describe under
<br />DESCRIPTION OF OPERATIONS below E.L. DISEASE -POLICY LIMIT $ 1,000,000
<br />D POLLUTION ICELLUW00156766 01/20/2024 01/20/2025 OCCURENCE $2,000,000
<br />DESCRIPTION OF OPERATIONS/ LOCATIONS/ VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space Is required)
<br />ATTENTION: Engineering Department
<br />RE: Lions Wayside and Delucchi Park Renovations, CIP No. 06716 -4401 First St, Pleasanton, CA 94566
<br />The City of Pleasanton, its officers, officials, employees and volunteers are included as Additional Insured per written contract with the Named
<br />Insured as respects: liability arising out of activities performed by or on behalf of the Named Insured; products and completed operations of the
<br />Named Insured; premises owned, occupied or used by the Named Insured; or automobiles owned, leased, hired or borrowed by the Named Insured.
<br />Coverage afforded to Additional Insured is Primary and Non-Contributory. The coverage afforded by the policies will not be reduced, canceled, or
<br />allowed to expire without at least 30-days written notice to City.
<br />CERTIFICATE HOLDER CANCELLATION
<br />SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED OR
<br />MODIFIED BEFORE THE EXPIRATION DATE THEREOF , THE ISSUING
<br />City of Pleasanton COMPANY WILL MAIL 30 DAYS WRITTEN NOTICE TO THE CERTIFICATE
<br />123 Main Street HOLDER NAMED TO THE LEFT
<br />Pleasanton, CA 94566 AUTHORIZED REPRESENTATIVE
<br />I ~ (MAA)
<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: B44A2432-4811-426C-B5F5-6E9650A4B84F
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