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HomeMy WebLinkAboutT-5815 - Certificate of Insurance - 3/13/2013 y of MITI MEMORANDUM rn=-:0:: ...- PUBLIC WORKS DEPARTMENT LAND DIVISION 2600 FRESNO STREET FRESNO,CA 93721 DATE: November 15, 2012 TO: HEIDI BRIGGS Personnel Services Department FROM: JONATHAN BARTEL Public Works Department SUBJECT: REQUEST FOR CERTIFICATE OF LIABILITY AND ENDORSEMENT OF INSURANCE APPROVAL FOR THE FINAL MAP OF TRACT NO. 5815 Attached are certificates of liability insurance required for the subdivision agreement for the Final Map. Please review for conformity to City acceptance policies. If you have any questions, please contact me at 621-8684. Thank you, r:, C-. •c _�3-C Jonathan Bartel �� 2{r3rn 3� v SANM ,a►coRO CERTIFICATE OF LIABILITY INSURANCE 7TE(MM/DD/YYYY) 128/2012 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 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). ONTACT PRODUCER (949)221-1788 NAME: Maria Sanducci D.L.D. Insurance Brokers,Inc. a/c°No Ext: 949 553-5696 Fa No: 949 221-1797 Lic#OD25325 E-MAIL 17712 Mitchell North ADDRESS:msanducci@dldins.com Irvine, it 92614 PRODUCER ic),WOODGRO-01 INSURERS)AFFORDING COVERAGE NAIC 0 INSURED Pleasant Valley Investments, LC INSURER A:As en_S! ep cialt Insurance Woodside Group, LLC INSURER B:Phiiadel hia Insurance Companies 39 East Eagleridge Drive INSURERC:Alterra Excess&Surplus Insurance Co. Suite 100 INSURER D:Everest National Ins.Co. North Salt Lake, UT 84054 lNsuRSRR:Westchester INSURER F:lronshore Indemnity COVERAGES CERTIFICATE NUMBER: 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. INSR TYPE OF INSURANCE IA"DL SIIBR� POLICY EFF POLICY E1 LIMITS LTR I SR POLICY NUMBER MMID.,YYY MM/ODIYYYY GENERAL LIABILITY EACH OCCURRENCE S 5,000,00 `04NIA�E�I�ETIYED A X COMMERCIAL GENERAL LIABILITY X X 595X003968012 12/31/2012 12/31/201$ PREMISES(Ea occurrence) �$ CIAIMS-MAOE OCCUR MED EXP(Any one person) PERSONAL&ADV INJURY_ _$ 5,000,00 1 GENERAL AGGREGATE S 5,000,00 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 5,000,00 X Poucy PRO- FA LOG S AUTOMOBILE LIABILITY X COMBINED SINGLE LIMIT S 2,000,00 B X ANY AUTO PHPK886224 7/1/2012 7/1/2013 (Eaacudent) BODILY INJURY(Per person) $ ALL OWNED AUTOS - --- BODILYINJURY(Peraccident) $ SCHEDULED AUTOS PROPERTY DAMAGE $ HIRED AUTOS (Peraccident) yy NON-OWNED AUTOS I$ $ UMBRELLA LIAB X OCCUR EACH OCCURRENCE _ $ 5,DOO,000 XEXCESS LIAB CLAIMS-MADE AGGREGATE $ 5,000, C 886781127XSCC2C12 12/31/2012 12/31/2015 OW DEDUCTIBLE $ RETENTION $ $ WORKERS COMPENSATIONX TWO STATO OTH- AND EMPLOYERS'LIABILITY T , ER ___ D ANY PROP RI ETOR/PARTNER/EXECUTIVE YIN X CA10001232121 7/1/2012 7/1/2013 E.L.EACH ACCIDENT $ 1,000,00 OFFICERIMEMBER EXCLUDED? F—] NIA (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE?S 1,400,00 If yes,descnbe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 1,000,00 7E Professional Liability 624106469004 12/3112012 12/31/2013 Retro Date:8120/2008 ImPer Claim/$2mAggr F Excess Liability 001570200 12/31/2012 12131/201$ 2nd Excess Layer $10,000,00 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101,Additional Remarks Schedule,if more spa�RI[ISTe DEMENT G I I I h ! See attached page. tli�4 App oved: Ap;u•oved Ch4011s: CERTIFICATE HOLDER CANCELLATION r 4001- i� A� SIC: .='d Dato SHOULD ANY OF 1'I'IE BOVE DESCRIBED POLICIES BE CANCELLED BEFORE Ci of Fresno THE EXPIRATION DI>FlE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Attn:Ken Turner 2600 Fresno Street,Room 3076 Fresno,CA 93721-3612 AUTHORIZED REPRESENTATIVE - ©1988-2009 ACORD CORPORATION. All rights reserved. ACORD 25(2009/09) The ACORD name and logo are registered marks of ACORD WOODGRO-01 SANM PAGE 1 OF 1 DESCRIPTION OF OPERATIONS - Pleasant Valley Investments, LC City of Fresno Woodside Group, LLC 39 East Eagleridge Drive Attn: Ken Turner Suite 100 2600 Fresno Street, Room 3076 North Salt Lake, UT 84054 Fresno, CA 93721-3612 The City of Fresno, its officers, officials, employees,agents and volunteers are additional insured as respects to General and Auto Liability insurance. Such insurance as is afforded by the policy is primary and any other insurance shall be excess and not contribute to the insurance afforded by this endorsement.This insurance is primary,and our obligations are not affected by any other insurance carried by such additional insured whether primary,excess, contingent, or on any other basis.Waiver of subrogation for Workers'Compensation insurance as respects to the City of Fresno, its officers, officials, employees,agents and volunteers. POLICY NUMBER 595XO03968012 COMMERCIAL GENERAL LIABILITY THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - OWNERS, LESSEES or CONTRACTORS [Form B] This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Name of Person or Organization.- City rganization:City of Fresno Attn: Ken Turner 2600 Fresno Street, Room 3076 Fresno, CA 93721-3612 The City of Fresno, its officers, officials, employees, agents and volunteers are additional insured as respects to General and Auto Liability insurance, Such insurance as is afforded by the policy is primary and any other insurance shall be excess and not contribute to the insurance afforded by this endorsement. This insurance is primary, and our obligations are not affected by any other insurance carried by such additional insured whether primary, excess, contingent, or on any other basis.Waiver of subrogation for Workers' Compensation insurance as respects to the City of Fresno, its officers, officials, employees, agents and volunteers. (If no entry appears above, information required to complete this endorsement will be shown in the Declarations as applicable to this endorsement.) WHO IS AN INSURED (Section II) is amended to include as an insured the person or organization shown in the Schedule, but only with respect to liability arising out of "your work" for that insured by or for you. CG 20 10 11 85 Copyright, Insurance Service Office, Inc., 1984 POLICY NUMBER 595XO031810Z COMMERCIAL GENERAL LIABILITY THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - OWNERS, LESSEES or CONTRACTORS [Form B] This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Name of Person or Organization: City of Fresno, its officers, officials, employees, agents and volunteers 2600 Fresno Street, Room 3076 Fresno, CA 93721-3612 (If no entry appears above, information required to complete this endorsement will be shown in the Declarations as applicable to this endorsement.) WHO IS AN INSURED (Section II) is amended to include as an insured the person or organization shown in the Schedule, but only with respect to liability arising out of "your work" for that insured by or for you. CG 20 10 11 85 Copyright,Insurance Service Office,Inc., 1984 595 BES Attaching to Risk No Endorsement No Currency Gross Premium X003181OZ 011 Total Registration VAT TOCTribunal Lloyd's Serial Registration Category Sett due date Def Adj ILU LIRMA Assured/Account Companies PH Holding LLC General Underwriters Agreement(GUA) Each Underwriters proportion is several not'oint Slip Leader Only Slip Leader&Agreement Parties All Underwriters ADDITIONAL INSURED—OWNERS, LESSEES OR CONTRACTORS(FORM 13) This endorsement modifies insurance provided under the following with effect from 12th December 2012 COMMERCIAL GENERAL LIABILITY COVERAGE SCHEDULE Name of Person or Organization: City of Fresno, its officers, officials, employees, agents and volunteers 2600 Fresno Street, Room 3076 Fresno, CA 93721-3612 (If no entry appears above, information required to complete this ,endorsement will be shown in the Declarations as applicable to this endorsement.) WHO IS AN INSURED (Section II) is amended to include as an insured the person or organization shown in the Schedule, but only with respect to liability arising out of"your work" for that insured.by-yew=ep-fier� Such insurance as is afforded by this Endorsement is primary and any other insurance shall be excess and not contribute to the insurance afforded by this endorsement. ' All other terms and condition remain unaltered. London 13'h December 2012. Information: DLD Insurance email dared 12th December 2012 L.P. .O. number and date I.L.U.number and date L.I.R.KA.number and date Planned Settlement Date PI-MANU-1 (01100) THIS ENDORSEMENT CHANGES `CHE POLICY. PLEASE READ IT CAREFULLY CA2048 Designated Insured with Primary Wording POLICY NUMBER:PRPK886224 COMMERCIAL AUTO CA 20 48 02 99 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. DESIGNATED INSURED This endorsement modifies insurance provided under the following: BUSINESS AUTO COVERAGE FORM GARAGE COVERAGE FORM MOTOR CARRIER COVERAGE FORM TRUCKERS COVERAGE FORM With respect to cov6rage provided by this endorsement., the provisions of the Coverage Form apply unless modified by this endorsement. This endorsement identifies person(s) or organization(s) who are "insureds" under the Who Is An Insured Provision of the Coverage Form. This endorsement does not alter coverage provided in the Coverage Form. This endorsement changes the policy effective on the inception date of the policy unless another date is indicated below. Endorsement Effective: 7/1/2012 Countersigned By: Named Insured: PH Holding, LLC (Authorized Representative) SCHEDULE Name of Person(s) or Organization(s) The City of Fresno, its officers, officials, employees, agents and volunteers C/o Department of Public Works, Attn: Gary Witzel 2600 Fresno Street, 4th Floor, Rm 4064 Fresno, CA 93721-3623 THIS INSDRANCE IS PRIMARY AND NON-CONTRIBUTORY, AND OUR OBLIGATIONS ARE NOT AFFECTED BY ANY OTHER INSURANCE CARRIED BY THE PERSON OR ORGANIZATION TO WHOM THIS COVERAGE APPLIES, WHETHER PRIMARY, EXCESS, CONTINGENT OR ON ANY OTHER BASIS. All other terms and conditions of this Policy remain unchanged. Page 1 of 2 PI-MANU-1 (01100) THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY (If no entry appears above, information required to complete this endorsement will be shown in the Declarations as applicable to the endorsement. } Each person or organization shown in the Schedule is an "insured" for Liability Coverage, but only to the extent that person or organization qualifies as an "insured" under the Who Is An Insured Provision contained in Section II of the Coverage Form. CA 20 48 02 99 0 Insurance Services Office, Inc., 1998 All other terms and conditions of this Policy remain unchanged. Page 2 of 2 POLICY CHANGE DOCUMENT POLICY NO.: PH PK886224 Philadelphia Indemnity Insurance Companyl 5350 DLD INSURANCE BROKERS, INC. NAMED INSURED PH Holding, LLC MAILING ADDRESS 39 E Eagle Ridge Dr Ste 102 North Salt Lake, UT 84054-2641 POLICY PERIOD: FROM 07/01/2012 TO 07/01/2013 at 12:01 A.M. Standard Time at your mailing address shown above. CHANGE EFFECTIVE 12/01/2012 CHANGE# 3 DESCRIPTION In consideration of the premium reflected, the policy is amended as indicated below: AMENDED: Named Insured to include: Pleasant Valley Investments, LC ADDED: Additional Insured: The City of Fresno, its officers, officials, employees, agents and volunteers Attn: Ken Turner 2600 Fresno St Room 3076 Fresno, CA 93721-3612 Form: CA2048 Designated Insured Per attached schedule Path ID 6792548 Total Annual Total Prorate Additional/Return Premium$ 25.00 Additional/Return Premium$ 25.00 ADDITIONAL ADDITIONAL COUNTERSIGNED BY (Date) (Authorized Representative) Insurance Policy Page 1 of 1 Philadelphia Indemnity Insurance Company Additional Insured Schedule Policy Number: PHPK886224 Additional Insured City of Riverside Risk Management & City of Riverside 3900 Main St Riverside, CA 92522-0001 CA2048 - CA - Veh #0 - BI - AUTO-Designated Insured-Project Additional Insured The City of Fresno, its officers, officials, employees, agents, and volunteers Attn: Ken Turner 2600 Fresno St Rm 3076 Fresno, CA 93721-3620 CA2048 - CA - Veh #0 - BI - AUTO-Add[ Insured-The City of Fresno City requirement Page 1 of 1 Philadelphia Indemnity Insurance Company Named Insured Schedule Policy Number: PHPK886224 Woodside Communities-WDC,LLC Woodside Group, LLC Woodside Homes Corporation Woodside Homes of Arizona, Inc. Woodside Homes of California, Inc. Woodside Homes of Fresno, Inc. Woodside Homes of Minnesota, Inc. Woodside Homes of Nevada, Inc. Woodside Homes of North Florida, Inc. Page 1 of 2 Philadelphia Indemnity Insurance Company Named Insured Schedule Policy Number: PHPK886224 Woodside Homes of Northern California, Inc. Woodside Homes of Utah, Inc. Woodside Homes of Central California, Inc. Woodside Homes of South Texas, LLC Woodside Homes of Southeast Florida, LLC Pleasant Valley Investments, LC Page 2 of 2 POLICY NUMBER: PHPK886224 COMMERCIAL AUTO CA 20 48 02 99 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. DESIGNATED INSURED This endorsement modifies insurance provided under the following: BUSINESS AUTO COVERAGE FORM GARAGE COVERAGE FORM MOTOR CARRIER COVERAGE FORM TRUCKERS COVERAGE FORM With respect to coverage provided by this endorsement, the provisions of the Coverage Form apply unless modi- fied by this endorsement. This endorsement identifies person(s) or organization(s) who are "insureds" under the Who Is An Insured Provi- sion of the Coverage Form. This endorsement does not alter coverage provided in the Coverage Form. This endorsement changes the policy effective on the inception date of the policy unless another date is indicated below. Endorsement Effective: 12/01/2012 Countersigned By: Named Insured: PH Holding, LLC Authorized Representative) SCHEDULE Name of Person(s) or Organization(s): The City of Fresno, its officers, (If no entry appears above, information required to complete this endorsement will be shown in the Declarations as applicable to the endorsement.) Each person or organization shown in the Schedule is an "insured" for Liability Coverage, but only to the extent that person or organization qualifies as an "insured" under the Who Is An Insured Provision contained in Section II of the Coverage Form. CA 20 48 02 99 Copyright, Insurance Services Office, Inc., 1998 Page 1 of 1 ❑ WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 04 03 06 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 2 % of the California workers' compensation premium otherwise due on such remuneration. SCHEDULE PERSON OR ORGANIZATION JOB DESCRIPTION ANY PERSON OR ORGANIZATION FOR IF ANY WHOM THE NAMED INSURED HAS AGREED BY WRITTEN CONTRACT TO FURNISH THIS WAIVER. -7998 by the workers'Compensation Insurance Rating Bureau of Callforrda. All rights reserved. From the WCIRB's California Workers'Compensation Insurance t=omes Manual- 1999.