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HomeMy WebLinkAboutPM 2007-15 - Certificate of Insurance - 10/29/2008 TE9 0 /20088 _L D-aP. CERTIFICATE OF LIABILITY INSURANCE D10/ lDIYY 10/09 PRODUCER (805)549-7430 FAX (805)549-7044 THIS CERTIFICATE IS ISSUED ASA MATTER OF INFORMATION Neal-Truesdale Insurance Inc ONLYAND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AMEND, EXTEND OR License # 0368744 ALTER THE COVERAGE AFFORDED BYTHEPOLICIES BELOW. 1400 Madonna Road San Luis Obispo, CA 93405-6433 INSURERS AFFORDING COVERAGE NAIC# INSURED Mid State Investors, LLC INSURER.A. Indian Harbor Insurance Co. 4821 E1 Camino Real INSURER B Atascadero, CA 93422 INSURER C. INSURER D. INSURER E' COVERAGES THE POLICIES OF INSURANCE LISTED BELOWHAVE BEEN ISSUED TO THE INSURED NAMEDABOVE FOR THE POLICY PERIOD INDICATED.NOTWITHSTAN DING ANY REQUIREMENT,TERM OR CONDITION OFANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TONMICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TOALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH POLICIES,AGGREGATE LIMITS SHOM MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSRDD'L Ty pE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATIO DATE(MMIDDIYYI DATE(MMIDDNY) LIMITS GENERAL LIABILITY SL2715224 10/08/2008 10/08/2009 EACH OCCURRENCE $ 1-10-0-0-1000 Y COMMERCIAL GENERAL I-IABILITY DAMAGE TO RENTED $ CLAIMS MADE X I I OCCUR MED EXP(Any one person) $ 1,000 A X -- PERSONAL&ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 . GEN'LAGGREGATE LIMIT APPLIES PER , PRODUCTS-COMP/OP AGG $ 2,000,000 )( POLICY PROJECT LOC AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT ,MAY AUTO (Ea acadert) $ ALL OWNED AUTOS BODILY INJURY $ SCHEDULED AUTOS (Per person) HIRED AUTOS BODILY INJURY $ NON-O VVNED AUTOS (Per acadent) PROPERTY DAMAGE $ (Per accident) GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $ ANY AUTO OTHER THAN EA ACC $ AUTO ONLY AGG $ EXCESSAIMBRELLA LIABILITY A prOVed EACH OCCURRENCE $ OCCUR 0 CLAIMS MADE App oy9d W Chan eS. AGGREGATE $ IDS1 $ in , W DEDUCTIBLE $ RETENTION $ IC't '` Qf $ WORKERS COMPENSATION AND TORY LIIMITS OT EM PL OYERS'L I ABIL ITY ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? E.L.DISEASE-EA EMPLOYE $ It yes.descnbe Under SPECIAL PROVISIONS below E.L.DISEASE-POLICY LIMIT 1$ OTHER DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT 1 SPECIAL PROVISIONS ity of Fresno, its officers, agents, officials, employees & volunteers are named as additional insured s respects 2395 Blythe Ave, Fresno, CA 93722. This insurance is primary, and our obligations are not affected by any other insurance carried by an additional insured whether primary, excess, ontingent, or on any other basis. 0 Day Notice of Cancellation for Non-Payment of Premium CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE City of Fresno EXPIRATION DATE THEREOF,THE ISSUING INSURER WILIENDEAVOR TO MAIL 30 c/o Construction Management Division _ DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, Attn: Maryann Lewis BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LIABILITY 1721 Van Ness Ave OF ANY KIND UPON THE INSURER,ITS AGENTS OR REPRESENTATIVES. Fresno, CA 93721 AUTHORIZED REPRESENTATIVE f4(O Neal-Truesdale/DIANE / f ACORD 25(2001/08) ©ACORD CORPORATION 1988 IMPORTANT If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must be endorsed.A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). 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). DISCLAIM ER The Certificate of Insurance on the reverse side of thisform does not constitute a contract between the issuing insurer(s),authorized representative or producer,and the certificate holder,nor does it affirmatively or negatively amend,extend or alter the coverage afforded by the policies listed thereon. ACORD 25(2001108) ' INDIAN l AQ]52polio No. Policy tea. Y SL 2715224 SL 2715224 OUOTE Policy Period From: 10/08/2009 To: 1.0/08/2009 DF-ANS&HOIArFL SURPLUS LINES BROKE-9 At 12:01 A.M_ 340 pine Street,San Francisca, G A.94104 Standard Time 11�SU7RED: P°ROWMR(107091 MID STATE INVESTORS, LLC Neal-'LTrueisdale Insurance Inc. 4821 EL CAMINO REAL 1400 Madonna Road ATASCADERO, CA 93422-2759 San uigi ,ObisCACA 93405-5433 !111„14 fl]lit1Fll4111 �l1111111lfIR.1141 TERM Pltr WWUN s $1,010.00 Premium Tax $30.30 St,araping Fee $1.26 TQTAL . . . . . . . . . . $1.,041.56 LOCATION! #1 VACANT LAND 2395 BLYTHE AVE (CORNER BLYTHE & CLINTON) FRESNO, CA 93722 ' Coverage and conditions applicable to l.acation #1 PREMISES LIABIZ,IT:f INSURANCE COVERAGE LIMITS OF INSURANCE Premises Liability: Per Occurrence 'Limit $1, 000,000 Premises Liability; Annual Aggregate Limit $2, 000, 000 Premises Medigal Payments Limit - Each Person: $ 1,000 Each Accident-, $25,000 FORMS D-2 FORM (01-05) Surplus Lines D-R Farm DH 05=43 (02-03) Limitation on Acts of terrorism DH 47-05 (08-02) Premises Liability Insurance DR 47-'06 (08-05) Organic Pathogen Exclusion SPECIAL PROVZSIOW *IN CONSTDPRATION OF THE PREMIUM CHARGER, IT IS UNDEFZSTOOD AM AGREED THAT THE "OTHER INSURANCE,, CLAUSE ON PAGE 1.0 OF FORM DH47--DS (08-02) IS DEL.RTED IDI ITS ENTIRETY AND REPLACED WITH: THIS INSURANCE IS PRIMARY, AND OUR OBLIGATIONS ARE NOT AFFECTED BY ANY OVER INSURANCE CARRIED BY AN AMITIONAL INSURED WHETHER PRIA%RY, FRCESS, CONTINGENT, OR ON ANY OTHER BASIS. I DH-DHC (10-04) DECLARATIONS PAGE 1,0/09/08 BT.+ 2715224 ► pitge-- 2 -UL 271529. AWrTIC gML-TWrjWa§M. CXTY OF FRUa+T+C1, TTS OVPI,p+ 4, T$ Additla¢1d1 I OFrxCIALS MCK O1Y17a, & VC&U Qg atill�dd 1721 VAN I=$ AYQ_ rn'TKMO, CIL 93721-1130 i t4cxTICw 0o, �l,0yb.00 SPACIAL Mkow9zpw MUO pa1lCY Is m1bjaat t* a om aarrAwy preaLug of: $750 i grY: P*UTA Tate i i D�1 b C DRCW"TUMS PASS: 101G9169 f I r Mid State Investors, LLC 5067 N Mariposa Avenue Suite 102 Fresno, Ca 93710 Office (559) 241-0135 October 14, 2008 Jonathan Bartel City of Fresno Planning and Development Department 2600 Fresno Street Fresno, Ca 93721 Re: Worker's Compensation and Automobile Insurance, Parcel Map No. 2007-15 Mr. Bartel: Please note that we do not own automobiles or employ employees as part of our business. We sub contract all services and do not have any automobiles. Therefore, we have no requirements for these types of insurance coverage. Tac 5t re-r'ds. PercwiLliams. Pv1riaber