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HomeMy WebLinkAboutLea & Braze Engineering, Inc. (4)LEA&BRA-01 I RANKR AC®RZX CERTIFICATE OF LIABILITY INSURANCE DAT7/7/2 D/YYYY) 7/7/2022 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 License # OL72977 LegacyRisk & Insurance Services 1850 Mt. Diablo Blvd., Suite 400 cAMP cT Certificates Department PHONE FAX (A/C, No, Ext): (925) 482-1000 WC, N.):(925) 482-1001 Walnut Creek, CA 94596 ab Afiss: certificates@legacyrisk.net INSURERS AFFORDING COVERAGE NAIC # A019608800 A: Middlesex Insurance Company 23434 7/1/2023 INSURED -INSURER INSURER B : Arch Insurance Company 11150 INSURER C : Lea & Braze Engineering, Inc. INSURER D: 2495 Industrial Parkway West Hayward, CA 94545-5037 INSURER E INSURER F : GEN'L AGGREGATE LIMIT APPLIES PER: POLICY Fx_1 jE8T 7 LOC OTHER: COVERAGES CERTIFICATE NUMBER! RFVIRION NIIMRPR- 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 TYPE OF INSURANCE ADDL SUBR POLICY NUMBER POLICY EFF POLICY EXPLTR LIMITS A X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE X OCCUR X A019608800 7/1/2022 7/1/2023 EACH OCCURRENCE $ 1,000,000 DAMAGE TO RENTED 500,000 REMISESTYE Ea occurrence) MED EXP An one person)$ 15,000 PERSONAL & ADV INJURY 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: POLICY Fx_1 jE8T 7 LOC OTHER: GENERAL AGGREGATE $ 3,000,000 PRODUCTS - COMP/OP AGG $ 2,000,000 A AUTOMOBILE X LIABILITY ANY AUTO OWNED SCHEDULED AUTOS ONLY AUTOS ��yy AiJTEOS ONLY AUTOS ONNLY A019608800 7/1/2022 7/1/2023 COMBINED SINGLE LIMIT 1,000,000 Ea accident $ BODILY INJURY Perperson) $ BODILY INJURY Per accident Por. c1d t AMAGE A X UMBRELLA LIAB EXCESS LIAB X OCCUR CLAIMS -MADE A019608800 7/1/2022 7/1/2023 EACH OCCURRENCE $ 5,000,000 AGGREGATE $ DED I I RETENTION $ Aggregate 5,000,000 A WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y / N ANY FICEr1MEMBER EXCLUDED? ECUTIVE ❑ (anda ory In NFI) If yes, descdbe under DESCRIPTION OF OPERATIONS below N / A A019608800 71112022 7/1/2023 I 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 B Professional Liab. PAAEP0135801 12/31/2021 12/31/2022 Per Claim/Aggregate 5,000,000 DESCRIPTION OF OPERATIONS /LOCATIONS /VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space Is required) RE: 2221243 Cl - Edgerton Road The Town of Los Altos Hills, Its elective and appointed officers, employees, and volunteers are named as additional insureds 30 day notice of cancellation applies except for 10 day notice due to non-payment in premium. CERTIFICATE HOLDER CANCELLATION ACORD 25 (2016/03) ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Town of Los Altos Hills TownFremont THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Road ACCORDANCE WITH THE POLICY PROVISIONS. Los Altos Hills, CA 94022 AUTHORIZED REPRESENTATIVE ACORD 25 (2016/03) ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD POLICY NUMBERA019608800 COMMERCIAL GENERAL LIABILITY CG 2010 07 04 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. • • 11� U- • This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Name Of Additional Insured Person(s) Or Organization(s): Location(s) Of Covered Operations Any person or organization you are required to add as All locations per written contract, agreement or permit an Description: additional insured under a written contract or All jobs performed that have a written contract, agreement agreement or permit lin effect prior to any accident, injury, loss or damage Information required to complete this Schedule, if not shown above, will be shown in the Declarations. A. Section II - Who Is An Insured is amended to include as an additional insured the person(s) or organization(s) shown in the Schedule, but only with respect to liability for "bodily injury", "property damage" or "personal and advertising injury" caused, in whole or in part, by: 1. Your acts or omissions; or 2. The acts or omissions of those acting on your behalf; in the performance of your ongoing operations for the additional insured(s) at the location(s) designated above. CG 20 10 07 04 A019608800 Middlesex Insurance Company 1 00001 0000000000 22175 0 N B. With respect to the insurance afforded to these additional insureds, the following additional exclusions apply: This insurance does not apply to "bodily injury" or "property damage" occurring after: 1. All work, including materials, parts or equipment furnished in connection with such work, on the project (other than service, maintenance or repairs) to be performed by or on behalf of the additional insured(s) at the location of the covered operations has been completed; or 2. That portion of "your work" out of which the injury or damage arises has been put to its intended use by any person or organization other than another contractor or subcontractor engaged in performing operations for a principal as a part of the same project. © ISO Properties, Inc., 2004 Maf566-cfe1.43ae-8768-e68032d52c47 Page 1 of 1 06/24/2022 Enter your TIN in the appropriate box. The TIN provided must match the name given on line 1 to avoid .. Request for Taxpayer _ Give Form to the Form (Rev. October 2018) Identification Number and Certification entitles, it is your employer identification number (EIN). If you do not have a number, see How to get a requester. Do not Department of the Treasury send to the IRS. Internal Revenue Service ► Go to www.irs.govfFormW9 for instructions and the latest information. 1 Name (as shown on your Income tax return). Name is required on this line; do not leave this line blank. Lea & Braze Engineering, Inc. 2 Business name/disregarded entity name, if different from above _ co 3 Check appropriate box for federal tax classification of the person whose name is entered on line 1. Check only one of the 4 Exemptions (codes apply only to m following seven boxes. certain entities, not individuals; see CL C ❑ Individual/sole proprietor or ❑ C Corporation ✓❑ S Corporation ❑ Partnership ❑ Trust/estate instructions on page 3): ai c single member LLC Exempt payee code (if any) 6 ❑ Limited liability company. Enter the tax classification (C=C corporation, S=S corporation, P=Partnership) ► o Note: Check the appropriate box In the line above for the tax classification of the single -member owner. Do not check Exemption from FATCA reporting M LLC if the LLC is classified as a single -member LLC that is disregarded from the owner unless the owner of the LLC Is another LLC that Is not disregarded from the owner for U.S. federal tax purposes. Otherwise, a single -member LLC tt code (if any) y) Is disregarded from the owner should check the appropriate box for the tax classification of its owner. d ❑ Other (see instructions) ► (Applies to accounts maintained outside the U.S) CL 5 Address (number, street, and apt, or suite no.) See instructions. Requester's name and address (optional) 2495 Industrial Parkway West 6 City, state, and ZIP code Ha ward, CA 94545 7 List account number(s) here (optional) Mall Taxpayer Identification Number (TIN) Enter your TIN in the appropriate box. The TIN provided must match the name given on line 1 to avoid Social security number backup withholding. For individuals, this is generally your social security number (SSN). However, fora resident alien, sole proprietor, or disregarded entity, see the instructions for Part I, later. For other _ m entitles, it is your employer identification number (EIN). If you do not have a number, see How to get a TIN, later. or Note: If the account is in more than one name, see the instructions for line 1. Also see What Name and I Employer identification number Number To Give the Requester for guidelines on whose number to enter. F-j—j aMMMMMUMnE Certification Under penalties of perjury, I certify that: 1. The number shown on this form is my correct taxpayer identification number (or I am waiting for a number to be issued to me); and 2. 1 am not subject to backup withholding because: (a) I am exempt from backup withholding, or (b) I have not been notified by the Internal Revenue Service (IRS) that I am subject to backup withholding as a result of a failure to report all interest or dividends, or (c) the IRS has notified me that I am no longer subject to backup withholding; and 3. 1 am a U.S. citizen or other U.S, person (defined below); and 4. The FATCA code(s) entered on this form (if any) indicating that I am exempt from FATCA reporting is correct. Certification instructions. You must cross out item 2 above if you have been notified by the IRS that you are currently subject to backup withholding because you have failed to report all interest and dividends on your tax return. For real estate transactions, item 2 does not apply. For mortgage interest paid, acquisition or abandonment of secured property, cancellation of debt, contributions to an individual retirement arrangement (IRA), and generally, payments other than interest and dividends, you are not required to sign the certification, but you must provide your correct TIN. See the instructions for Part II, later. sign Signature ofDocuSignetl by: Here U.S. person I+i',� 0_�ez Date► 1/10/2022 X15t2,1 aC9C701486... General Instrucilons Section references are to the Internal Revenue Code unless otherwise noted. Future developments. For the latest information about developments related to Form W-9 and its instructions, such as legislation enacted after they were published, go to www.1rs.gov/F6rmlN9. Purpose of Form An individual or entity (Form W-9 requester) who is required to file an information return with the IRS must obtain your correct taxpayer identification number (TIN) which may be your social security number (SSN), individual taxpayer identification number (RIN), adoption taxpayer identification number (ATIN), or employer identification number (EIN), to report on an information return the amount paid to you, or other amount reportable on an information return. Examples of information returns Include, but are not limited to, the following. • Form 1099 -INT (interest earned or paid) • Form 1099 -DIV (dividends, including those from stocks or mutual funds) • Form 1099-MISC (various types of income, prizes, awards, or gross proceeds) • Form 1099-B (stock or mutual fund sales and certain other transactions by brokers) • Form 1099-S (proceeds from real estate transactions) • Form 1099-K (merchant card and third party network transactions) • Form 1098 (home mortgage interest), 1098-E (student loan interest), 1098-T (tuition) • Form 1099-C (canceled debt) • Form 1099-A (acquisition or abandonment of secured property) Use Form W-9 only if you are a U.S. person (including a resident alien), to provide your correct TIN. If you do not return Form W-9 to the requester with a TIN, you might be subject to backup withholding. See What is backup withholding, later. Cat. No. 10231X Form W-9 (Rev. 10-2018)