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HomeMy WebLinkAboutCertificate of Liability 24-25ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? INSR ADDL SUBR LTR INSD WVD PRODUCER CONTACT NAME: FAXPHONE (A/C, No):(A/C, No, Ext): E-MAIL ADDRESS: INSURER A : INSURED INSURER B : INSURER C : INSURER D : INSURER E : INSURER F : POLICY NUMBER POLICY EFF POLICY EXPTYPE OF INSURANCE LIMITS(MM/DD/YYYY)(MM/DD/YYYY) AUTOMOBILE LIABILITY UMBRELLA LIAB EXCESS LIAB WORKERS COMPENSATION AND EMPLOYERS' LIABILITY DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) AUTHORIZED REPRESENTATIVE EACH OCCURRENCE $ DAMAGE TO RENTEDCLAIMS-MADE OCCUR $PREMISES (Ea occurrence) MED EXP (Any one person)$ PERSONAL & ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER:GENERAL AGGREGATE $ PRO-POLICY LOC PRODUCTS - COMP/OP AGGJECT OTHER:$ COMBINED SINGLE LIMIT $(Ea accident) ANY AUTO BODILY INJURY (Per person)$ OWNED SCHEDULED BODILY INJURY (Per accident)$AUTOS ONLY AUTOS HIRED NON-OWNED PROPERTY DAMAGE $AUTOS ONLY AUTOS ONLY (Per accident) $ OCCUR EACH OCCURRENCE CLAIMS-MADE AGGREGATE $ DED RETENTION $ PER OTH- STATUTE ER E.L. EACH ACCIDENT E.L. DISEASE - EA EMPLOYEE $ If yes, describe under E.L. DISEASE - POLICY LIMITDESCRIPTION OF OPERATIONS below INSURER(S) AFFORDING COVERAGE NAIC # COMMERCIAL GENERAL LIABILITY Y / N N / A (Mandatory in NH) SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. 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. 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(ies) 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). COVERAGES CERTIFICATE NUMBER:REVISION NUMBER: CERTIFICATE HOLDER CANCELLATION © 1988-2015 ACORD CORPORATION. All rights reserved.ACORD 25 (2016/03) CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DD/YYYY) $ $ $ $ $ The ACORD name and logo are registered marks of ACORD 3/11/2025 License # 0C36861 (925) 280-4671 CSG Consultants, Inc. 550 Pilgrim Drive Foster City, CA 94404 26093 21105 21113 10046 A 1,000,000 X 5432352732 12/4/2024 12/4/2025 300,000 10,000 1,000,000 2,000,000 2,000,000 1,000,000B X 72APB010186 12/4/2024 12/4/2025 5,000,000C 5821248132 12/4/2024 12/4/2025 5,000,000 10,000 D 4087479726 12/4/2024 12/4/2025 1,000,000 1,000,000 1,000,000 E Professional Liab 83 OH 0489503-24 12/4/2024 Ea Claim/Agg 5,000,000 Re: Professional Services Agreement The Town of Los Altos Hills, its elective and appointed officers, employees and volunteers are included as additional insureds on GL & Auto with 30 Day Notice of Cancellation per attached. Town of Los Altos Hills 26379 Fremont Road Los Altos Hills, CA 94022 CSGCONS-01 JPERRY3 Alliant Insurance Services, Inc. 560 Mission St 6th Fl San Francisco, CA 94105 Julia Perry julia.perry@alliant.com United States Fire Insurance Company Nationwide Affinity Insurance Company of America North River Insurance Company United States Fire Insurance Company Pacific Insurance Company, Limited X 12/4/2025 X X X X X X X MG 20 003 06 18 Page 1 of 3 Includes copyrighted material of Insurance Services Office, Inc., with its permission. THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. CONTRACTORS SCHEDULED AND BLANKET ADDITIONAL INSUREDS ENDORSEMENT This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Name of Additional Persons or Organizations:Designated Projects or Locations: A. Section II – Who Is An Insured is amended to include as an additional insured any person or organization that you are required by “written contract” to add as an additional insured on this policy. In addition, if a person or organization is scheduled above, Who Is An Insured is amended to also include that person or organization as an additional insured. B. The insurance provided to the additional insured is limited as follows: 1. The person or organization is an additional insured only with respect to: a. 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 in the performance of your ongoing operations for the additional insured as specified in the “written contract”; or b. “Bodily injury” or “property damage” included within the “products-completed operations hazard” and caused in whole or in part by “your work” specified in the “written contract”, but only if: (1) The “written contract” requires you to provide the additional insured such coverage; (2) This policy provides such coverage; and (3) The loss occurs within the period of time required by the “written contract” and prior to the expiration date of the policy. 2. This policy will not provide the additional insured with any broader coverage or any higher limit of insurance than the lesser of: a. Coverage afforded under this policy; or b. Coverage required by the “written contract”. 3. Coverage provided by this endorsement to an additional insured shall be excess over any other valid and collectible insurance available to the additional insured, whether on a primary, excess, contingent or any other basis, unless the “written contract” requires that MG 20 003 06 18 Page 2 of 3 Includes copyrighted material of Insurance Services Office, Inc., with its permission. this insurance apply on a primary and non-contributory basis. 4. The insurance provided to the additional insured does not apply to “bodily injury”, “property damage” or “personal and advertising injury” arising out of: a. An architect’s, engineer’s or surveyor’s rendering of, or the failure to render any professional services, including: (1) The preparing, approving, or failure to prepare or approve maps, shop drawings, opinions, reports, surveys, field orders, change orders or drawings and specifications; and (2) Supervision or inspection performed as part of any related 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 policy. C. Section IV – Commercial General Liability Conditions is amended as follows: 1. Duties In The Event Of Occurrence, Offense, Claim Or Suit is amended to add the following: An additional insured under this endorsement will as soon as practicable: (1)Give us prompt written notice of any “occurrence” or offense which may result in a claim or “suit” under this insurance, and of any actual claim or “suit”; (2) Except as provided in Paragraph B.3. of this endorsement, agree to make available any other insurance the additional insured has for a loss we cover under this policy; (3) Immediately forward all legal papers to us, cooperate with us in the investigation, defense, or settlement of the claim or “suit”, and otherwise comply with the policy conditions; and (4) Tender the defense and indemnity of any claim or “suit” to any other insurer whose policy may provide coverage for a loss covered under this endorsement including, but not limited to, any insurer that has issued a policy under which the additional insured qualifies as an insured; however, if the “written contract” requires this insurance to be primary and non-contributory, this provision does not apply to insurance on which the additional insured is a Named Insured. We have no duty to defend or indemnify an additional insured under this endorsement until we receive written notice of a claim or “suit” from the additional insured. D. Only for the purpose of the insurance provided by this endorsement, Section V – Definitions is amended to add the following definition: “Written contract” means a written contract or written agreement that requires you to make a person or organization an additional insured under this policy, provided the contract or agreement: a. Is currently in effect or becomes effective during the term of this policy; and b. Was signed and executed prior to the “bodily injury” or “property damage” or “personal MG 20 003 06 18 Page 3 of 3 Includes copyrighted material of Insurance Services Office, Inc., with its permission. and advertising injury” for which coverage under this policy is sought by the additional insured. All other terms and conditions remain unchanged. Policy: 5432352732 Policy: 5432352732 Policy: 5432352732 Policy: 5432352732 Policy: 5432352732 Policy: 5432352732 Policy: 5432352732 Policy: 5432352732 Policy: 5432352732 Policy: 5432352732 MI 02 051 10 18 Page 1 of 1 Includes copyrighted material of Insurance Services Office, Inc., with its permission. THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. THIRD-PARTY NOTICE OF CANCELLATION OR NONRENEWAL This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE First Named Insured: CSG Consultants, Inc. Policy Number: 5432352732 Policy Period: 12/4/2024 – 12/4/2025 Endorsement Effective Date: Number of Days’ Notice - Nonpayment of Premium: 30 Number of Days’ Notice - All Other Reasons: 10 Name And Mailing Address/Email Address of Third Party: Per attached schedule If we cancel or nonrenew this Policy, we will mail, email, or otherwise deliver notice of cancellation or nonrenewal to the Third Party shown in the Schedule above at the address shown. A copy of the third-party notification will also be mailed or delivered to the first Named Insured. The minimum number of days prior to the cancellation or nonrenewal that the notice will be mailed or delivered is shown in the Schedule above. All other terms and conditions remain unchanged. Policy: 4087479726 WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 04 03 06 (Ed. 04-84) WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT−CALIFORNIA We have the right to recover our payments from anyone liable for an injury covered by this policy. We will not enforce 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 _____% of the California workers’ compensation premium otherwise due on such remuneration. Schedule Person or Organization Job Description Any person or organization with whom or with which you have agreed in a written contract to waive your right of recovery against, provided such written contract: See wording under Person or Organization 1. is currently in effect or will be come effective during the term of this policy; and 2. was executed and became effective prior to the occurrence of the injury covered by this policy. This form only applies in CA. This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated. Endorsement Effective Policy No. 4087479726 Endorsement No. Insured Insurance Company Countersigned By Policy: 72APB010186 M-5526 (09/2010) THIS ENDORSEMENT MODIFIES THE POLICY. PLEASE READ IT CAREFULLY. PROVISION OF EXTENDED NOTICE OF CANCELLATION If this policy is canceled, we will mail notice of cancellation to the persons or organizations named in the Schedule. We will give the number of days ' notice indicated in the Schedule plus three calendar days for mail time. SCHEDULE Name of Person(s) or Organization(s)Number of Days' Notice Address SEE ATTACHED LIST N/A 30 N/A, CA 11111 M-5526 (09/2010) (The Attaching Clause need be completed only when this endorsement is issued subsequent to preparation of the policy .) (Authorized Representative) Company Name Policy Number Endorsement Effective Countersigned byNamed Insured All other terms, conditions, and exclusions remain unchanged. National Fire & Marine Insurance Company CSG CONSULTANTS INC 72APB010186 12/04/2024 12:01 AM Holder Name Holder Address NOC X