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HomeMy WebLinkAboutCertificate of Insurance 2018LEA&BRA-01 I MARTINF7 CERTIFICATE OF LIABILITY INSURANCE DATE (MMIDDIYYYY) TYPE OF INSURANCE 10/15/2018 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(les) must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER Legacy Risk & Insurance Services, LLC 1850 Mt. Diablo Blvd., Suite 400 NAMEACT Certificates Department PHONE FAX (AIC, No, Ext): (925) 482-1000 (AIC, No):(925) 482-1001 Walnut Creek, CA 94596 a DRIEss: certificates@legacyrisk.net INSURERS AFFORDING COVERAGE NAIC # INSURERA:Continental Insurance Co 35289 07/01/2018 INSURED INSURER B: American Casualty Company 20427 INSURER C: Insurance Co. of The West 27847 Lea & Braze Engineering, Inc. INSURER D: Underwriters of Llo d"s 15792 2496 Industrial Parkway West Hayward, CA 94545-5037 X INSURER E: INSURER F: COVFRAGF_S CIPRTIPICATP Kl IMRPR• owrcino ten. THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR LTRI TYPE OF INSURANCE ADDL SUBR p POLICY NUMBER POLICY EFF POLICDY EXP IYYYYI LIMITS A X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE ® OCCUR 6072482937 07/01/2018 07/01/2019 EACH OCCURRENCE $ 1,000,000 DAMAGE TO RENTED 100,000 PREMISES FR occurrence $ MED EXP (Any oneperson) $ 15,000 X PERSONAL &ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: POLICY � JECT LOC GENERAL AGGREGATE $ 2,000,000 PRODUCTS -COMP/OPAGG $ 2,000,000 OTHER: B AUTOMOBILE JX LIABILITY ANY AUTO 0 TUOS ONLY AUTOSULED 6072482940 07/01/2018 07/01/2019 Ea aBcid DISINGLE LIMIT $ 1,000,000 BODILY INJURY Per erson $ BODILY INJURY Per accident $ AUR OS ONLY X AU OS ONLY Pe�accRde,t DAMAGE $ UMBRELLA LIAR HOCCUR EACH OCCURRENCE $ AGGREGATE $ EXCESS LIAB CLAIMS -MADE DED 11 $ C WORKERS COMPENSATION AND EMPLOYERS' LIABILITY YIN ANY OFFICER/MEMB�R�/EXCLUDED?ECUTIVE ❑ (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below N/A WPL504193000 07/01/2018 07/01/2019 X PER OTH- STATUTE ER E. L. EACH ACCIDENT $ 1,000,000 E.L. DISEASE - EA EMPLOYEE $ 1,000,000 E.L. DISEASE -POLICY LIMIT $ 1,000,000 D Professional Liab. ANE165795117 12/31/2017 12/31/2018 Per Claim/Aggregate 2,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS /VEHICLES (ACORD 101, Additional Remarks Schedule maybe attached if more space is required) Project Number: 2181256 Cl RE: Town Hall Expansion. The Town of Los Altos Hills, its elective and appointed officers, employees, and volunteers are named as additional insureds with respects to General Liability. 30 Day notice of cancellation applies to GL, Auto, WC. Town of Los Altos Hills 26379 Fremont Road Los Altos Hills, CA 94022 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE gaxb�, KQ6-.._.. At,UKU AD (zu1 u/ud) ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD i ri g ! III I r, AGENCY CUSTOMER ID. LEA&BRA-01 LOC #: 0 LMARTINEZ Page 1 of 1 AGENCY Legacy Risk & Insurance Services, LLC NAMED INSURED Lea & Braze Engineering, Inc. 2495 Industrial Parkway West Hayward, CA 94546.5037 POLICY NUMBER EE PAGE 1 CARRIER EE PAGE 1 NAIC CODE SEE P 1 EFFECTIVE DATE: SEE PAGE 1 ADDITIONAL REMARKS THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, FORM NUMBER: ACORD 25 FORM TITLE: Certificate of Liability Insurance THE FOLLOWING ENDORSEMENTS APPLY ONLY AS INDICATED IN THE DESCRIPTION OF OPS GENERAL LIABILITY FORMS: *Blanket Additional Insured, Primary & Non -Contributory, Blanket Waiver of Subro. per Form- CNA74858XX 1-15 -*As required by written Contract. *Blanket Additional Insured -Owners, Lessees or Contractors with Products Completed Operations Per Form - CNA75079xx 10/16 - *As required by written Contract * Waiver of Subrogation Per Form CNA75008xx 10/16 - *As required by written Contract Auto Liability Forms: *Additional Insured - Primary & Non Contributory Wording- Waiver of Subro. per Form CNA63359xx 04/12 *As required by written contract * Additional Insured -Lessor Per CA2001 10/13 - *As required by written contract *Loss Payable Clause - Per CA9944 10/13 - *As required by written contract * Waiver of Subrogation - Per CA044410/13 - *As required by written Contract WORKERS COMPENSATION FORMS: * Waiver of Subrogation perform WC990634 -As required by written contract. *10 Day Notice of Cancellation for Non -Payment of Premium. ACORD 101 (2008/01) © 2008 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD :4� A'Tc1 Blanket Additional Insured - Owners, Lessees or Contractors - with Products -Completed Operations Coverage Endorsement This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART It is understood and agreed as follows: I. WHO IS AN INSURED is amended to include as an Insured any person or organization whom you are required by written contract to add as an additional insured on this coverage part, but only with respect to liability for bodily injury, property damage or personal and advertising injury caused in whole or in part by your acts or omissions, or the acts or omissions of those acting on your behalf: A. in the performance of your ongoing operations subject to such written contract; or B. in the performance of your work subject to such written contract, but only with respect to bodily injury or property damage included in the products -completed operations hazard, and only if: 1. the written contract requires you to provide the additional insured such coverage; and 2. this coverage part provides such coverage. II. But if the written contract requires: A. additional insured coverage under the 11-85 edition, 10-93 edition, or 10-01 edition of CG2010, or under the 10-01 edition of CG2037; or B. additional insured coverage with "arising out of language; or C. additional insured coverage to the greatest extent permissible by law; then paragraph I. above is deleted in its entirety and replaced by the following: WHO IS AN INSURED is amended to include as an Insured any person or organization whom you are required by written contract to add as an additional insured on this coverage part, but only with respect to liability for bodily injury, property damage or personal and advertising injury arising out of your work that is subject to such written contract. III. Subject always to the terms and conditions of this policy, including the limits of insurance, the Insurer will not provide such additional insured with: A. coverage broader than required by the written contract; or B. a higher limit of insurance than required by the written contract. IV. The insurance granted by this endorsement to the additional insured does not apply to bodily injury, property damage, or personal and advertising injury arising out of: A. the rendering of, or the failure to render, any professional architectural, engineering, or surveying services, including: 1. the preparing, approving, or failing to prepare or approve maps, shop drawings, opinions, reports, surveys, field orders, change orders or drawings and specifications; and 2. supervisory, inspection, architectural or engineering activities; or B. any premises or work for which the additional insured is specifically listed as an additional insured on another endorsement attached to this coverage part. V. Under COMMERCIAL GENERAL LIABILITY CONDITIONS, the Condition entitled Other Insurance is amended to add the following, which supersedes any provision to the contrary in this Condition or elsewhere in this coverage part: CNA75079XX (10-16) Page 1 of 2 Policy No: 6072482937 Endorsement No: 2 Effective Date: 7/1/2018 Insured Name: Copyright CNA All Rights Reserved. Includes copyrighted material of Insurance Services Office, Inc., with its permission. Blanket Additional Insured - Owners, Lessees or Contractors - with Products -Completed Operations Coverage Endorsement Primary and Noncontributory Insurance With respect to other insurance available to the additional insured under which the additional insured is a named insured, this insurance is primary to and will not seek contribution from such other insurance, provided that a written contract requires the insurance provided by this policy to be: 1. primary and non-contributing with other insurance available to the additional insured; or 2, primary and to not seek contribution from any other insurance available to the additional insured. But except as specified above, this insurance will be excess of all other insurance available to the additional insured. VI. Solely with respect to the insurance granted by this endorsement, the section entitled COMMERCIAL GENERAL LIABILITY CONDITIONS is amended as follows: The Condition entitled Duties In The Event of Occurrence, Offense, Claim or Suit is amended with the addition of the following: Any additional insured pursuant to this endorsement will as soon as practicable: 1. give the Insurer written notice of any claim, or any occurrence or offense which may result in a claim; 2. except as provided in Paragraph IV. of this endorsement, agree to make available any other insurance the additional insured has for any loss covered under this coverage part; 3. send the Insurer copies of all legal papers received, and otherwise cooperate with the Insurer in the investigation, defense, or settlement of the claim; and 4. tender the defense and indemnity of any claim to any other insurer or self insurer whose policy or program applies to a loss that the Insurer covers under this coverage part. However, if the written contract requires this insurance to be primary and non-contributory, this paragraph (4) does not apply to insurance on which the additional insured is a named insured. The Insurer has no duty to defend or indemnify an additional insured under this endorsement until the Insurer receives written notice of a claim from the additional insured. VII. Solely with respect to the insurance granted by this endorsement, the section entitled DEFINITIONS is amended to add the following definition: Written contract means a written contract or written agreement that requires the Named Insured to make a person or organization an additional insured on this coverage part, provided the contract or agreement: A. is currently in effect or becomes effective during the term of this policy; and B. was executed prior to: 1. the bodily injury or property damage; or 2. the offense that caused the personal and advertising injury for which the additional insured seeks coverage. Any coverage granted by this endorsement shall apply solely to the extent permissible by law. All other terms and conditions of the Policy remain unchanged. This endorsement, which forms a part of and is for attachment to the Policy issued by the designated Insurers, takes effect on .the effective date of said Policy at the hour stated in said Policy, unless another effective date is shown below, and expires concurrently with said Policy. CNA75079XX (10-16) Page 2 of 2 Policy No: 6072482937 Endorsement No: 3 Effective Date: 7/1/2018 Insured Name: Copyright CNA All Rights Reserved. Includes copyrighted material of Insurance Services Office, Inc., with its permission. Policy# 6072482937 G-1 5115-A CNA(Ed. 10/89) THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. CHANGES - NOTICE OF CANCELLATION OR MATERIAL COVERAGE CHANGE This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART LIQUOR LIABILITY COVERAGE PART OWNERS AND CONTRACTORS PROTECTIVE LIABILITY COVERAGE PART POLLUTION LIABILITY COVERAGE PART PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE PART RAILROAD PROTECTIVE LIABILITY COVERAGE PART In the event of cancellation or material change that reduces or restricts the insurance afforded by this Coverage Part (other than the reduction of aggregate limits through payment of claims), we agree to mail prior written notice of cancellation or material change to: SCHEDULE 1.Number of days advance notice: 30 Days 2. Name: Town of Los Altos Hills 3. Address: 26379 Fremont Road Los Altos Hills, CA 94022 G -15115-A Page 1 of 1 (Ed. 10/89) G -300660-A (Ed. 06/08) THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. CHANGES - NOTICE OF CANCELLATION OR MATERIAL CHANGE This endorsement modifies insurance provided under the following: BUSINESS AUTO COVERAGE FORM GARAGE COVERAGE FORM TRUCKERS COVERAGE FORM This endorsement changes the policy effective on the inception date of the policy unless another date is indicated below: Endorsement Effective 07/10/2018 Policy Number 6072482940 Named Insured Lea & Braze Engineering, Inc. Countersigned by (Authorized Representative In the event of cancellation or material change that reduces or restricts the insurance afforded by this Coverage Part, we agree to mail prior written notice of cancellation or material change to: SCHEDULE 1. Number of days advance notice: 30 Days 2. Name: Town of Los Altos Hills 3. Address: 26379 Fremont Road Los Altos Hills, CA 94022 G -300660-A Page 1 of 1 (Ed. 06/08) LEGACY Risk & Insuronce Services, LLC October 15, 2018 Town of Los Altos Hills 26379 Fremont Road Los Altos Hills, CA 94022 RE: Lea and Braze Engineering, Inc. Project Description: Town Hall Expansion To Whom it May Concern: Regarding the above -referenced project, you are requiring, our client, Lea and Braze Engineering, Inc., to have their Workers Compensation & Professional Liability carriers issue an endorsement that provides 30 day notification of cancellation to you for the above -referenced project. Their Workers Compensation carrier and Professional Liability carriers do not offer this endorsement. We, Legacy Risk & Insurance Services, as the Insurance Broker for Lea and Braze Engineering, Inc. will assume all responsibility for providing Town of Los Altos Hills with a 30 Day Notice of Cancellation. Sincerely, 904� �6� Lesette Banks Assistant Account Manager 1850 Mt. Diablo Blvd, Suite 400 • Walnut Creek, CA 94596 ♦ p 925.482.1000 ♦ f925.482.1001 a www.legacyrisk.net ♦ CA License #OH66758