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HomeMy WebLinkAboutFerma Corporation (3)05260028002 COMMERCIAL AUTO *Starr Indemnity & Liability Company SICA-1016 (0919) THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. r - ADDITIONAL INSURED - AUTOMATIC STATUS AMENDATORY ENDORSEMENT Policy Number: 1000198707221 Effective Date- 10/1/22022 Named Insured: FERMA CORPORATION This endorsement modifies the insurance coverage form(s) listed below that have been purchased by you and evidenced as such on the Declarations page. Please read the endorsement and respective pollcy(les) carefully, AUTO DEALERS COVERAGE FORM BUSINESS AUTO COVERAGE FORM MOTOR CARRIER COVERAGE FORM It is hereby agreed that SECTION 11 — COVERED AUTOS LIABILITY COVERAGE, A. COVERAGE, 1. Who Is An Insured of the Business Auto Coverage Form and Motor Carrier Coverage Form, and SECTION I — COVERED AUTOS COVERAGES, D. Covered Autos Liability Coverage, 2. Who Is An Insured of the Auto Dealers Coverage Form are amended to Include the following: Any person or organization whom you become obligated to include as an additional insured under this policy, as a result of any written contract or written agreement you enter into which requires you to furnish insurance to that person or organization of the type provided by this policy, but only with respect to liability arising out of use of a covered "auto". However, the insurance provided will not exceed the less of: (1) The coverage and/or limits of this policy, or (2) The coverage and/or Ili -nits required by such written contract or written agreement, All other terms and conditions of this Policy remain unchanged. SICA-1016 (0919) Copyright @ Starr Indemnity & Liability Company, All rights reserved. Page I of I Includes copyrighted material of Insurance Services Office, Inc., with its permission. P5260028002 POLICY NUMBER: 1000198707221 COMMERCIAL AUTO CA 04 4410 13 a w O THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. WAIVER OF TRANSFER OF RIGHTS OF RECOVERY In AGAINST OTHERS TO US (WAIVER OF SUBROGATION) This endorsement modifies insurance provided under the following: AUTO DEALERS COVERAGE FORM BUSINESS AUTO COVERAGE FORM MOTOR CARRIER COVERAGE FORM With respect to coverage provided by this endorsement, the provisions of the Coverage Form apply unless modified by the endorsement. This endorsement changes the policy effective on the inception date of the policy unless another date is indicated below. Named Insured: FERMA CORPORATION Endorsement Effective Date: 10/1/2022 SCHEDULE Name(s) Of Person(s) Or Organization(s): W4er a Requi r ed by W i t t en Cont r act Information required to corn fete this Schedule, if not shown above, will be shown in the Declarations. The Transfer Of Rights Of Recovery Against Others To Us condition does not apply to the person(s) or organization(s) shown in the Schedule, but only to the extent that subrogation is waived prior to the "accident' or the 'loss" under a contract with that person or organization. CA 04 4410 13 © Insurance Services Office, Inc., 2011 Page 1 of 1 P5200028002 ■ WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 04 03 06 -- (Ed 04-84) w WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT - CALIFORNIA w 0 We have the right to recover our payments from anyone liable for an injury covered by this policy. We will not enforce 00 our right against the person or organization named in the Schedule. (This agreement applies only to the extent that you perform work under a written contract that requires you to obtain this agreement from us.) You must maintain payroll records accurately segregating the remuneration of your employees while engaged in the work described in the Schedule. The additional premium for this endorsement shall be 2.0% of the California workers' compensation premium otherwise due on such remuneration. Schedule Person or Organization Job Description Any per son or or gani zat i on t o whom you becorre obi i gat ed t o Val ve Where Required By W I t t en your r I ght s of r ecover y age] nst , under any oont r act or agr eerrent you Cont r act ent er i nt o pr i or t o t he occur r once of I oss. This endorsement changes the policy to which it is attached and Is effective on the date Issued unless otherwise stated. (The Information below Is required only when this endorsement Is issued subsequent to preparation of the policy.) Endorsement Effective: 10/01/2022 Policy No.: 1000004374 Endorsement No.: Insured: Ferma Corporation Premium: Insurance Company: STARR INDEMNITY & LIABILITY Co Countersigned by: WC 04 03 06 (Ed. 04-84) Page 1 of 1 P5260028002 McSherry & Hudson, An Alera Group Company 1901 S, Bascom Avenue Suite 1190 Campbell, CA 95008 Electronic Service Requested SINGLE PIECE 6575 3.3477 SP 0.600 1'III'I1I1Ilulllll'lu�lungill oull1lu1IIIIMIIuIInllluull111lllll City of Los Altos Hills 191 263`17 Fremont Road Los Altos, CA 94022 0-1 This document was brought to you by Certificatesnrow. If you have questions regarding the content of this document, please contact - the Producer/Agent listed on the certificate of insurance or the insured listed - on the notice of cancellation/reinstatement.- cc: The data included in this notice and in the attached document is confidential to Ebix BPO and the party responsible for bringing you this Information. Certificate Delivery by CertlficatesNow - www.ConflrmNet.com - 677.669.9600 Nvm 0 rn 115260028002 0 WUMITM ACbRr®®DATE \rr.►'� CERTIFICATE OF LIABILITY INSURANCE (MMIDDIYYYY) 09/29/2022 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 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 endorsementt s), PRODUCER LIC #OM77949 1•-888--845-2248 MoSherry & Hudson, An Alera Group Company 1901 S. easacm Avenue Suite 1190 Campbell, CA 95008 CONTACT �— NAM :PHONE __ __ FAX taCC,.�o,ct)`.`�08-550-2130 All C,NoI; 408-550-2119 _ E MAIL — ADDRESS: -INSURERS OVERAGE- — (-) AFFORDING C--- - NAIC ff — INSU_RERA; g1'ARR rND & LTAB CO_ 38318 Charles M. Griswold INSURED T ��-- INSURER : HOMESITE 3:NS CO - B 17221 Ferma Corporation -'---"`-T — -- INSURERC: Tokio Marine Specialty Insurance Compare "-"�— 23850 D: -� _ 6639 Smith Avenue -INSURER INSURER E: Newark, CA 94560 $ 100,000 MEDEXP (AnyoneeraP on) $ 10,000 INSURER F: $ 1,000,000 COVERAGES CERTIFICATE NUMBER: 66773691 REVISION NUMBER: 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. ?LTR LTR OF INSURANCE _ _.T AbDi 6U9 POLICY NUMBER POLICY EFF IRWRDIYYYJY PgLICY EXP-- IMMIDDIYYYYIJLIMITS -- `-'— A GENERAL LIABILITY X X 1000025823211 10/01/2 10/01/23 EACH OCCURRENCE $1,000,000 XA COMMERCIAL GENERAL LIABILITY - CLAIMS -MADE � OCCUR AGETORENTED PREMISES Eaw Qccurranco_ $ 100,000 MEDEXP (AnyoneeraP on) $ 10,000 PERSONAL INJURY $ 1,000,000 _&ADV GENERAL AGGR_E_GATE — $2,000,000 GE_N'LAGGREGATE LIMIT APPLIES PER: _ PRODUCTS - COMPIOPAGG $2,000,000 _ POLICY X PRO- JECT LOC $-- _ A AUTOMOBILE _ LIABILITY X X 1000198707211 10/01/22 10/01/23 COMBINED SINGLE LIMIT Eaaccl enl _ — 110 00,000 __ BODILY INJURY (Par person) $ X ANY AUTO I ALL OWNED SCHEDULED TOS AUTOS BODILY INJURY (Par accident) $-r� PROPERTY DAMAGE (Peraccide-n $ X NON OWNED HIRED AUTOS X I. AUTOS X OCCUR T CXP-010622-00 10/01/2 10/01/23 EACHOCCURREN_C_E_ - - — $ 5,000,000 X EXCESS LIAB CLAIMS -MADE AGGREGATE_ $ 5,000,000 FAUMBRELLALIAB DED RETENTION $ - - -- FOLLOW FORM $ WORKERS COMPENSATION AND EMPLOYERS'LIABILITY PROPRIETORIPARTNER/EXECUTIVE YIN OFFICERIMEMBER EXCLUDED? (Mandatory In NH) NIA X 1000004374 10/01/2 /0101/23 0TH - X 0$YL,Ii'dLTR -ANY E.L. EACH ACCIDENT — $ 1,000,000 E.L. DISEASE - EA EMPLOYEE -- $ 1,000,000 f Yes, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE- POLICY LIMIT 1, 000, 000 C Pollution Liability PPK9 2 a ng a Aggregate low lox C Professional Liability PPK2471162 10/01/2 10/01/23 Single/Aggregate 5M/lOM DESCRIPTION OF OPERATIONS LOCATIONS IVEHICLES (Attach ACORD 101, Additional Remarks Schedule, If more space is required) RE: Encroachment Permit. Additional Insured: City of Los Altos Hills. CERTIFICATE HOLDER CANCELLATION O 1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25 (2010105) The ACORD name and logo are registered marks of ACORD Grezelle24 66773691 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE City of LOS Altos Hills THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS, 26397 Fremont Road AUTHORIZED REPRESENTATIVE Los Altos, CA 94022 gz4vo USA O 1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25 (2010105) The ACORD name and logo are registered marks of ACORD Grezelle24 66773691 P5260028002 SUPP (05/04) DATE SUPPLEMENT TO CERTIFICATE OF INSURANCE 09/29/2022 NAME OF INSURED: Forma Corporation rOmPaqP- AMINO DOLP 9-ra-L0—nsJ—Ben Eirks from PagP- Mdit onal MdItLonLI alfqn "10- includes: General Liability'. Additional insured per forms attached CG20100413 and CG20370413. Coverage is Primary as required by written contract per from attached 00 107 (04-11). Per Project Aggregate per attached form CG25030509. Waiver of Subrogation as required by written contract per attached form CG24040509. Automobile Liability: Additional insured per attached form SICA-1016 (0919). Primary and Non -Contributory Wording per attached form SICA-1037 (0919). Waiver of Subragation per attached form CA04441.013. Workers Compensation: Waiver of Subrogation per attached form WC040306 (Ed. 4-84). L---,- SUPP (05/04) P5260028002 a 0 �i R *Starr Indemnity & Liability Company Dallas, TX 1-866-519-2522 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED — OWNERS, LESSEES OR CONTRACTORS — SCHEDULED PERSON OR . ORGANIZATION Policy Number: 1000025823221 Effective Date: October 1, 2022 at 12:01 A.M Named Insured: FERMA CORPORATION . This endorsement modifies insurance provided under the: COMMERCIAL GENERAL LIABILITY COVERAGE PART Name Of Additional Insured Person(s) Or Organization(s): Location(s) Of Covered Operations Wier a Requi r ed by W i t t en Cont r act W4er a Requi r ed by W i t t en Cont r act 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: 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. 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. Ota 22104 (10114) Page 1 of 2 Copyright m C. V. Starr & Company and Starr Indemnity & Liability Company. All rights reserved. Includes copyrighted material of 180 Properties, Inc„ used with Its permission. Starr Indemnity & Liability Company Dallas, TX 1-866-519-2522 All other terms and conditions of this Policy remain unchanged. Signed for STARR INDEMNITY & LIABILITY COMPANY Steve Blakey, President OG 22104 (10114) 1i1o"al' Nehemiah E. Ginsburg, Genera ounsel Copyright © C. V. Starr & Company and Starr Indemnity d Liability Company. All rights reserved. Includes copyrighted material of ISO Properties, Inc., used with Its permission. Page 2 of 2 w O r5260028002 r r2, POLICY NUMBER: 1000025823221 COMMERCIAL GENERAL LIABILITY CG 25 03 05 09 w THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. DESIGNATED CONSTRUCTION PROJECT(S) GENERAL AGGREGATE LIMIT This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Designated Construction Project(s): Ner a Requl r ed by VW I t t an Cont r act Information required to complete this Schedule, if not shown above, will be shown in the Declarations. A. For all sums which the insured becomes legally obligated to pay as damages caused by "occur- rences" under Section I — Covera( )a A, and for all medical expenses caused by accidents under Section I — Coverage C, which can be attributed only to ongoing operations at a single designated construction project shown in the Schedule above: 1. A separate Designated Construction Project General Aggregate Limit applies to each des- ignated construction project, and that limit is equal to the amount of the General Aggregate Limit shown in the Declarations. 2. The Designated Construction Project General Aggregate Limit is the most we will pay for the sum of all damages under Coverage A, ex- cept damages because of "bodily injury" or "property damage" included in the "products - completed operations hazard", and for medi- cal expenses under Coverage C regardless of the number of: a. Insureds; b. Claims made or "suits" brought; or c. Persons or organizations making claims or bringing "suits". 3. Any payments made under Coverage A for damages or under Coverage C for medical expenses shall reduce the Designated Con- struction Project General Aggregate Limit for that designated construction project. Such payments shall not reduce the General Ag- gregate Limit shown in the Declarations nor shall they reduce any other Designated Con- struction Project General Aggregate Limit for any other designated construction project shown in the Schedule above. 4. The limits shown in the Declarations for Each Occurrence, Damage To Premises Rented To You and Medical Expense continue to apply. However, instead of being subject to the General Aggregate Limit shown in the Decla- rations, such limits will be subject to the appli- cable Designated Construction Project Gen- eral Aggregate Limit. CG 25 03 05 09 O Insurance Services Office, Inc., 2008 Page 1 of 2 ❑ P5260028002 O B. For all sums which the insured becomes legally C. When coverage for liability arising out of the obligated to pay as damages caused by 'occur- "products -completed operations hazard" is pro- rences" under Section I — Coverage A, and for all vided, any payments for damages because of medical expenses caused by accidents under "bodily injury" or "property damage" included in Section I — Coverage C, which cannot be attrib- the "products -completed operations hazard" will uted only to ongoing operations at a single des- reduce the Products -completed Operations Ag- ignated construction project shown in the Sched- gregate Limit, and not reduce the General Ag- ule above: gregate Limit nor the Designated Construction 1. Any payments made under Coverage A for Project General Aggregate Limit. damages or under Coverage C for medical D. If the applicable designated construction project expenses shall reduce the amount available has been abandoned, delayed, or abandoned under the General Aggregate Limit or the and then restarted, or if the authorized contract - Products -completed Operations Aggregate ing parties deviate from plans, blueprints, de - Limit, whichever is applicable; and signs, specifications or timetables, the project will 2. Such payments shall not reduce any Desig- still be deemed to be the same construction pro- nated Construction Project General Aggre- ject. gate Limit. E. The provisions of Section III — Limits Of Insur- ance not otherwise modified by this endorsement shall continue to apply as stipulated. Page 2 of 2 © Insurance Services Office, Inc., 2008 CG 25 03 05 09 ❑ 0 ('