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HomeMy WebLinkAboutT-5603 - Certificate of Insurance - 6/9/2009 ACORDTM CERTIFICATE OF LIABILITY INSURANCEDATE(MM/DD/YYYY) PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE Lockton Risk Services HOLDER THIS CERTIFICATE DOES NOT AMEND, EXTEND OR P.O. sox 410679 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Kansas City, MO 64141-0679 INSURERS AFFORDING COVERAGE NAIC# INSURED Habitat for Humanity of Fresno, Inc. INSURER A: Federal Insurance Cc 20281 INSURER B: Vigilant Insurance Company 2219 San Joaquin Street INSURER C: INSURER D: Fr sno, CA 93721-1126 INSURER E: COVERAGES 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.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR OkOD'L POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATIONLTR LUM-TYPE OF INSURANCE LIMITS A GENERAL LIABILITY LI064450-09 4/01/2009 4/01/2010 EACH OCCURRENCE $ DAMAGE TO RENTED COMMERCIAL GENERAL LIABILITY PREMISES Ea occurence $ CLAIMS MADE ALJ OCCUR MED EXP(Any one person) $ X PERSONAL&ADV INJURY $ GENERAL AGGREGATE $ GENT AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ POLICY PROjECTLOC A AUTOMOBILE LIABILITY 0973513123 4/01/2009 04/01/2010 COMBINED SINGLE LIMIT X ANY AUTO (Ea accident) $ 1,000,000 ALL OWNED AUTOS BODILY INJURY SCHEDULED AUTOS (Per person) $ HIRED AUTOS BODILY INJURY $ NON-OWNED AUTOS (Per accident) PROPERTY DAMAGE $ (Per accident) GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $ ANY AUTO RISK MANAGEM NT DMS ON OTHER THAN EA ACC $ AUTO ONLY: AGG S EXCESS/UMBRELLA LIABILITY Appro e • EACH OCCURRENCE $ OCCUR C CLAIMS MADE hang AGGREGATE $ + $ DEDUCTIBLE signed Qt $ RETENTION $ C.�+i $ WORKERS COMPENSATION AND I T WC STRY LIMIT OER MIT ER TH- EMPLOYERS' LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ OFFICERIMEMBER EXCLUDED? E.L. DISEASE-EA EMPLOYE $ If yes,describe under SPECIAL PROVISIONS below E.L.DISEASE-POLICY LIMIT $ B OTHER R1064450-09 4/01/2009 04/01/2010 Limit $2,000,000 Builders Risk Deductible $2,500 - Special Form DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS The City of Fresno, its officers, officials, employees, agents and volunteers are additional insured as respects to general and auto liability insurance. This insurance is primary, and our obligations are not affected by any other insurance carried by such additional insured whther primary, excess, contingent or on any other basis. Re: Subdivision Agreement Tract No. 5603 CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION City of Fresno DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 1 0 DAYS WRITTEN Construction Management Division NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO SO SHALL Attn: Maryann Lewis IMPOSE NO OBLIGATION OR LIABILITY OF ANY FOND UPON THE INSURER ITS AGENTS OR 1721 Van Ness Avenue REPRESENTATIVES. Fresno, CA 93721 AUTHORIZED RE'RESEdTATIVE ACORD 25(2001/08) ©ACORD CORPORATION 1988 DS#7280969 1064450 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). DISCLAIMER The Certificate of Insurance on the reverse side of this form 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(2001/08) Liability Insurance Endorsement Policy Period APRIL 1,2009 TO APRIL 1,2010 Effective Date APRIL 1,2009 Policy Number 3578-17-0'ATL Insured HABITAT FOR HUMANITY PURCHASING GROUP INC Name of Company FEDERALINSURANCE COMPANY Date Issued APRIL 15,2009 This Endorsement applies to the following forms: GENERAL LIABILITY - n'yrt�54Q'���»L'4�S�SFa�u+w..F.�..�.'�SO�•�"a"'.y�eri w�Fiifsa�RtS�'QiC�^��^t�"'•"l�Ein ii>»�.ro.1�,.FrF....'aR...=...+:: oL�itQcrs�uP"ne:lGT..NF4� �C �aC�d�_s� iLSL�ii_�i Under Conditions,the following condition is added: Conditions Otherinsurance v If you agree,in a written contract,agreement or permit,to provide primary insurance for any PrimaryAdditional person or organization included in Who Is An Insured,this Other Insurance` Primary Additional Insured Insured condition applies. If other valid and collectible insurance is available to the insured for loss we would otherwise cover under this insurance,our obligations are limited as follows. Primary Insurance This insurance is primary.We will not seek contributions from any other insurance available to the person or organization with whom you agree to include in Who Is An Insured,except when the Excess Insurance provision applies. Excess Insurance This insurance is excess over any other insurance,whether primary,excess,contingent or on any other basis: A. that is Fire,Extended Coverage,Builder'sRisk,Installation Risk or similar insurance for your work; UabilityInsurance Other Insurance"Primary AddrRtf a Copy continued Form 80-02-2653'Ed.4-01) Endorsement Page 1 B. General Conditions d. When this Coverage Form and any other 1. Bankruptcy Coverage Form or policy covers on the same basis, either excess or primary, we Bankruptcy or insolvency of the insured or the will pay only our share. Our share is the "insured's" estate will not relieve us of any obli- proportion that the Limit of Insurance of gations under this Coverage Form. our Coverage Form bears to the total of 2. Concealment,Misrepresentation Or Fraud the limits of all the Coverage Forms and This Coverage Form is void in any case of policies covering on the same basis. fraud by you at any time as it relates to this 6. Premium Audit Coverage Form. It is also void if you or any other"insured", at any time, intentionally con- a. The estimated premium for this Coverage ceal or misrepresent a material fact concern- Form is based on the exposures you told us you would have when this policy began. mg. We will compute the final premium due a. This Coverage Form; when we determine your actual exposures. b. The covered"auto"; The estimated total premium will be cred- ited against the final premium due and the c. Your interest in the covered"auto";or first Named Insured will be billed for the d. A claim under this Coverage Form. balance, if any. If the estimated total pre- mium exceeds the final premium due, the 3. Liberalization first Named Insured will get a refund. If we revise this Coverage Form to provide b. If this policy is issued for more than one more coverage without additional premium year,the premium for this Coverage Form charge, your policy will automatically provide will be computed annually based on our the additional coverage as of the day the revi- rates or premiums in effect at the begin- sion is effective in your state. ning of each year of the policy. 4. No Benefit To Bailee -Physical Damage Cov- 7. Policy Period,Coverage Territory erages We will not recognize any assignment or grant Under this Coverage Form, we cover "acci- any coverage for the benefit of any person or dents' and"losses" occurring: organization holding, storing or transporting a. During the policy period shown in the property for a fee regardless of any other provi- Declarations;and sion of this Coverage Form. b. Within the coverage territory. 5. Other Insurance The coverage territory is: a. For any covered"auto" you own, this Cov- erage Form provides primary insurance. a. The United States of America; For any covered "auto" you don't own, the b. The territories and possessions of the insurance provided by this Coverage Form United States of America; is excess over any other collectible insur- ance. However, while a covered "auto" c. Puerto Rico; and which is a"trailer" is connected to another d. Canada. vehicle,the Liability Coverage this Cover- We also cover"loss to or involving, Cover- age Form provides for the"trailer" is: g, a covered "auto" while being transported be- (1) Excess while it is connected to a motor tween any of these places. vehicle you do not own. S. Two Or More Coverage Forms Or Policies Is- (2) Primary while it is connected to a cov- sued By Us ered"auto"you own. b. For Hired Auto Physical Damage Cover- If this Coverage Form and any other Coverage Form or policy issued to you by us or any com- age, any covered "auto" you lease, hire, pany affiliated with us apply to the same acci- rent or borrow is deemed to be a covered dent" theaggregate maximum Limit of Insur- autoyou own. However, any auto that �� �' H "auto"�� ance under all the Coverage Forms or policies is leased,hired, rented or borrowed with a shall not exceed the highest applicable Limit of driver is not a covered"auto". Insurance under any one Coverage Form or c. Regardless of the provisions of Paragraph policy. This condition does not apply to any a, above, this Coverage Form's Liability Coverage Form or policy issued by us or an af- Coverage is primary for any liability as- filiated company specifically to apply as excess sumed under an"insured contract'. insurance over this Coverage Form. Page S of 10 Copyright,Insurance Services Office,Inc., 1996 CA 00 01 07 97 ❑ tzHuE3ra Liability Insurance Endorsement Policy Period APRIL 1,2008 TO APRIL_ 1,2009 Effective Date APRIL 1,2008 Policy Number 3578-17-07 ATL Insured HABITAT FOR HUMANITY PURCHASING GROUP INC Name of Company FEDERAL INSURANCE,COMPANY Date Issued MAY 9,2008 :�;"';:'.�K":.a;ir4•'.NY.r: Y:3:w'.'w....�.'3;E..�.;,SH;X3d+FKirx'Y3e 6xYv...',-XaR:YtAF:CNsklf:#:!•de8va`�snc.:nP4`.n.;�.'Kx'i-et::A�i'ra. �tY.':rrik6�'cti�`,`i'»m...,. y"?�r.. .=-';..a..:Y.tw..�:�A .:.i)>a....�'.:-...:r.WK A-".a:>3C�'+'.^".^< This Endorsement applies to the following forms: GTTIERAL LIABILITY Under Who Is An Insured,the following provision is added: Who Is An Insured Scheduled Person or Organization Subject to all of the terms and conditions of this insurance,any person or organization shown in the Schedule,acting pursuant to a written contract,agreement or permit between you and such person or organization,is an insured;but they are insureds only with respect to liability arising out of your operations,or your premises,if you are obligated,pursuant to such contract or agreement,to provide them with such insurance as is afforded by this policy. However,no such person or organization is an insured with respect to any: *assumption of liability by them in a contract or agreement.This limitation does not apply , to the liability for damages for injury or damage,to which this insurance applies, that the person or organization would have in the absence of such contract or agreement. *damages arising out of their sole nefligence. Liability Insurance ADDITONAL INSURED continued Form 80-02-2373(Ed.4-34) Endorsement Page 1 Who Is An Insured Scheduled Person Or Organization Schedule Persons or organizations that you are obligated,pursuant to written contract, agreement or permit between you and such person or organization,to provide with such insurance as is afforded by this policy;but they are insureds only if and to the minimum extent that such contract,agree- ment or permit requires the person or organization to be afforded status as an insured. However,no person or organization is an insured under this provision who is more specifically described under any other provision of'the Who Is An Insured section of this policy(regardless of any limitation applicable thereto). All other terms and conditions remain unchanged. Authorized Pa resentatiye Liability Insurance ADDITONAL INSURED last page Form 80-02.2373(Ed.4-94) Endorsement Page 2 Liability Insurance Endorsement Policy Period APRIL 1,2009 TO APRIL 1,2010 Effective Date APRIL 1,2009 Policy Number 3578-17-0'ATL Insured HABITAT FOR HUMANITY PURCHASING GROUP INC Name of Company FEDERALINSURANCE COMPANY Date Issued APRIL 15,2009 This Endorsement applies to the following forms: GENERAL LIABILITY �_W�-•:.. ,'�r���: 3s`C.gC :}v 'a �..��.,�,� '.�, ;��-��"+��3 !1:?�$x"�"r..:.`:�-:�nd��'3�'a�' t rzs� c�.,t�`�4,s �t?si� ��_=�.���'�� :.�i Under Conditions,the following condition is added: Conditions Otherinsurance' If you agree,in a written contract,agreement or permit,to provide primary insurance for any PrimaryAdditional person or organization included in Who Is An Insured,this Other Insurance' Primary Additional Insured Insured condition applies. If other valid and collectible insurance is available to the insured for loss we would otherwise cover under this insurance,our obligations are limited as follows. Primary Insurance This insurance is primary.We will not seek contributions from any other insurance available to the person or organization with whom you agree to include in Who Is An Insured,except when the Excess Insurance provision applies. Excess Insurance This insurance is excess over any other insurance,whether primary,excess,contingent or on any other basis: A. that is Fire,Extended Coverage,Builder'sRisk,Installation Risk or similar insurance for your work, Liability Insurance Otherinsurance"Primary AddSaf a Copy continued Form 80--02-2653'Ed.4-01) Endorsement Page 1 POLICYHOLDER COPY NE STATE P.O. BOX 420807, SAN FRANCISCO,CA 94142-0807 COMPENSATION INSURANCE FUND CERTIFICATE OF WORKERS' COMPENSATION INSURANCE ISSUE DATE: 04-14-2009 GROUP: POLICY NUMBER: 1910531-2008 CERTIFICATE ID: 5 CERTIFICATE EXPIRES: 10-01-2009 10-01-2008/10-01-2009 CITY OF FRESNO NE CONSTRUCTION MANAGEMENT DIVISION 1721 VAN NESS AVE FRESNO CA 93721-1130 This is to certify that we have issued a valid Workers' Compensation insurance policy in a form approved by the California Insurance Commissioner to the employer named below for the policy period indicated. This policy is not subject to cancellation by the Fund except upon 10 days advance written notice to the employer. We will also give you 10 days advance notice should this policy be cancelled prior to its normal expiration. This certificate of insurance is not an insurance policy and does not amend, extend or alter the coverage afforded by the policy listed herein. Notwithstanding any requirement, term or condition of any contract or other document with respect to which this certificate of insurance may be issued or to which it may pertain, the insurance afforded by the policy described herein is subject to all the �terms, exclusions, and conditions, of such policy. \ THORIZED REPRESENTATI (J PRESIDENT EMPLOYER'S LIABILITY LIMIT INCLUDING DEFENSE COSTS: $1,000,000 PER OCCURRENCE. ENDORSEMENT #2570 ENTITLED WAIVER OF SUBROGATION EFFECTIVE 2009-04-14 IS ATTACHED TO AND FORMS A PART OF THIS POLICY. THIRD PARTY NAME: CITY OF FRESNO EMPLOYER HABITAT FOR HUMANITY FRESNO, INC. NE 2219 SAN JOAQUIN ST FRESNO CA 93721 [MMJ,CNI (REV.2-05) PRINTED : 04-14-2009 WAIVER OF SUBROGATION NOTICE Enclosed is your copy of a certificate of insurance on which the certificate holder required a waiver of subrogation: 1. Please be advised that a waiver of subrogation requires that a 3% surcharge will be applied by State Fund ONLY to the premium assessed on the payroll of your employees earned while engaged in work for that certificate holder who requested the waiver. (Note: if you have no employee payroll on that job, then there is no charge.) 2. To apply the 3% surcharge, you must also agree to maintain accurately segregated payroll records for employees engaged in work on job/s for the certificate holder who has the waiver. The payroll records are subject to verification by an auditor. Example: Payroll for job: $5, 000 . 00 Sample Rate : 13 . 300 Regular Premium equals : $ 665 . 00 Surcharge : 3 . 00% Additional Waiver charge : $ 19 . 95 Total premium equals $ 684 . 95 (665 . 00 + 19 . 95)