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Docusign Envelope ID: FC72E12A-E2DD-42C4-BD36-C422ACOA54D2
<br />® DATE (MMIDD(YYYY)
<br />,a`oRV CERTIFICATE OF LIABILITY INSURANCE
<br />7/5/2022
<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 />NAME:__ Carley Resnik
<br />Edgewood Partners Insurance Center PHONE - IF
<br />P.O. Box 2110 _WC..N0. E*I (916)352-0492_ No 916 583-7613
<br />Rancho Cordova CA 95670 naDRess: carley.resnik e.icbrokers.com
<br />INSURER(S) AFFORDING COVERAGE NAIC #
<br />License#: OB29370 INSURER: BETA Healthcare Group_ 99900
<br />INSURED AXISCOMM INSURERS: Federal Insurance Company _ 202B1
<br />Axis Community Health, Inc.
<br />5925 West Las Positas Blvd Suite 100 INSURERC: _ _-• _
<br />Pleasanton CA 94588 INSURERD:
<br />INSURER E :
<br />INSURER F :
<br />/'.c1'f TIC 1^ AT C wusoco. 4O Ow cC90 RF1/ICIr1N NIIMRFR•
<br />vTHIS 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 />EXP
<br />INSI I TYPE OF INSURANCE IADOLISUBRI POLICY NUMBER MO DD/YYYY I MMl POLICY OrYYYY LIMITS
<br />LTRan WVn
<br />A
<br />X
<br />COMMERCIAL GENERAL LIABILITY
<br />HCL221064
<br />7/112022
<br />7/1/2023
<br />EACH OCCURRENCE
<br />$4,000,000
<br />^
<br />CLAIMS -MADE a OCCUR
<br />_
<br />RENTED
<br />PRENIISES Ea occurrence
<br />$ 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 />PRODUCTS - COMP/OP AGG
<br />$Included
<br />qPOLICY El JECT LOC
<br />OTHER:
<br />B
<br />AUTOMOBILE LIABILITY
<br />2273609883
<br />711/2022
<br />7/1/2023
<br />C MBiNEDSINGLELIMIT
<br />E."clan"
<br />$1.000,000
<br />BODILY INJURY (Per person)
<br />$
<br />ANY AUTO
<br />BODILY INJURY (Per accident)
<br />$
<br />OWNED SCHEDULED
<br />AUTOS ONLY AUTOS•
<br />X HIRED X NON -OWNED
<br />AUTOS ONLY AUTOS ONLY
<br />PROPERTY DAMAGE
<br />tPOr,
<br />$
<br />UMBRELLALIAB
<br />OCCUR
<br />EACH OCCURRENCE
<br />$
<br />AGGREGATE
<br />$
<br />EXCESS LIAB
<br />CLAIMS -MADE
<br />DED I I RETENTION $
<br />$
<br />A
<br />WORKERS COMPENSATION
<br />AND EMPLOYERS' LIABILITY Y / N
<br />ANYPROPRIETOR/PARTNERIEXECUTIVE
<br />WC221064
<br />7/1/2022
<br />7/1/2023
<br />XI ERH
<br />STATUTE ER
<br />3.000,000
<br />E.L. EACH ACCIDENT
<br />$ 2,000_000
<br />E L. DISEASE- EA EMPLOYEE
<br />OFFICER/MEMBER EXCLUDED? ❑
<br />(Mandatory In NH)
<br />N /A
<br />$ 2.000,000
<br />If yes, describe under
<br />DESCRIPTION OF OPERATIONS below
<br />E L DISEASE -POLICY LIMIT
<br />s2,000,000
<br />B
<br />A
<br />Cane - Employee Theft
<br />Professional Liability Inc's A&M
<br />Claims Made / Relro dale 5/1/77
<br />82553413
<br />HCL221064
<br />7/1/2022
<br />7/1/2022
<br />7/1/2023
<br />7/1/2023
<br />Limit / Deductible
<br />Each Claim load
<br />Policy Aggregate /0ed
<br />$400,000 I $2,000
<br />$4.000.000 /$0
<br />$5,000,000/ $0
<br />DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, maybe attached If more space Is required)
<br />Excess Worker's Compensation, Carrier: Safety National Casually Corporation, NAIC #15105, Policy #SP4065056, Term: 07/01122-07/01/23, Statutory Limits
<br />Excess of $3,000,000.
<br />Cyber Liability - Carrier: Beazley; Policy Number: W32E2A2201; Policy Term: 07/01/22-07/01/23, Retroactive Date: 07/01/2019; Limit of Liability: $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 HOLDEK l.Ar41-r LLAI IVIY
<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 ACCORDANCE WITH THE POLICY PROVISIONS.
<br />volunteers
<br />PO Box 520 AUTHORIZED REPRESENTATIVE
<br />Pleasanton CA 94566
<br />U 19UU-ZUI b AGUKU GUKF'UKA I Ivry. Au ngnis reserveu.
<br />ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD
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