|
OP ID: JF
<br />CERTIFICATE OF LIABILITY INSURANCE
<br />DATE (MM/DD/YYYY)
<br />07/23/13
<br />THISCERTIFICATEISISSUEDASAMATTEROFINFORMATIONONLYANDCONFERSNORIGHTSUPONTHECERTIFICATEHOLDER.THIS
<br />CERTIFICATEDOESNOTAFFIRMATIVELYORNEGATIVELYAMEND,EXTENDORALTERTHECOVERAGEAFFORDEDBYTHEPOLICIES
<br />BELOW.THISCERTIFICATEOFINSURANCEDOESNOTCONSTITUTEACONTRACTBETWEENTHEISSUINGINSURER(S),AUTHORIZED
<br />REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER.
<br />IMPORTANT:IfthecertificateholderisanADDITIONALINSURED,thepolicy(ies)mustbeendorsed.IfSUBROGATIONISWAIVED,subjectto
<br />thetermsandconditionsofthepolicy,certainpoliciesmayrequireanendorsement.Astatementonthiscertificatedoesnotconferrightstothe
<br />certificate holder in lieu of such endorsement(s).
<br />CONTACT
<br />408-354-3030Joan Fabricius-Lyons
<br />PRODUCER
<br />NAME:
<br />Integra Insurance Services,Inc
<br />FAX
<br />PHONE
<br />408-354-3454408-335-1203408-354-3454
<br />14107 Winchester Blvd Suite V
<br />(A/C, No):
<br />(A/C, No, Ext):
<br />E-MAIL
<br />Los Gatos, CA 95032
<br />jlyons@integra-insurance.com
<br />ADDRESS:
<br />PRODUCER
<br />HTHAR-1
<br />CUSTOMER ID #:
<br />INSURER(S) AFFORDING COVERAGENAIC #
<br />Triple H S, Inc. dba:
<br />Hanover Insurance Co22292
<br />INSURED
<br />INSURER A :
<br />H T Harvey & Associates
<br />Landmark American Ins Co 33138
<br />INSURER B :
<br />983 University Avenue Suite D
<br />Sentinel Ins. Co./Hartford 19682
<br />INSURER C :
<br />Los Gatos, CA 95032
<br />Nationwide Mutual Ins Co.23787
<br />INSURER D :
<br />INSURER E :
<br />INSURER F :
<br />COVERAGESCERTIFICATE NUMBER:REVISION NUMBER:
<br />THISISTOCERTIFYTHATTHEPOLICIESOFINSURANCELISTEDBELOWHAVEBEENISSUEDTOTHEINSUREDNAMEDABOVEFORTHEPOLICYPERIOD
<br />INDICATED.NOTWITHSTANDINGANYREQUIREMENT,TERMORCONDITIONOFANYCONTRACTOROTHERDOCUMENTWITHRESPECTTOWHICHTHIS
<br />CERTIFICATEMAYBEISSUEDORMAYPERTAIN,THEINSURANCEAFFORDEDBYTHEPOLICIESDESCRIBEDHEREINISSUBJECTTOALLTHETERMS,
<br />EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
<br />ADDLSUBR
<br />INSRPOLICY EFFPOLICY EXP
<br />TYPE OF INSURANCELIMITS
<br />POLICY NUMBER
<br />LTR(MM/DD/YYYY)(MM/DD/YYYY)
<br />INSRWVD
<br />1,000,000
<br />GENERAL LIABILITY
<br />EACH OCCURRENCE$
<br />DAMAGE TO RENTED
<br />AXXX ZHF926115201 09/01/1209/01/13500,000
<br />COMMERCIAL GENERAL LIABILITY$
<br />PREMISES (Ea occurrence)
<br />X 10,000
<br />CLAIMS-MADEOCCURMED EXP (Any one person)$
<br />AX Contractual Liab 1,000,000
<br />PERSONAL & ADV INJURY$
<br />2,000,000
<br />GENERAL AGGREGATE$
<br />Included
<br />GEN'L AGGREGATE LIMIT APPLIES PER:PRODUCTS - COMP/OP AGG$
<br />PRO-
<br />X Emp Ben.1,000,000
<br />$
<br />POLICYLOC
<br />JECT
<br />X
<br />COMBINED SINGLE LIMIT
<br />AUTOMOBILE LIABILITY
<br />1,000,000
<br />$
<br />(Ea accident)
<br />DX ACPBA7815192937 09/01/1209/01/13
<br />ANY AUTO
<br />BODILY INJURY (Per person)$
<br />ALL OWNED AUTOS
<br />BODILY INJURY (Per accident)$
<br />SCHEDULED AUTOS
<br />PROPERTY DAMAGE
<br />$
<br />(Per accident)
<br />HIRED AUTOS
<br />Comprehensive.500
<br />$
<br />NON-OWNED AUTOS
<br />Collision500
<br />$
<br />XX 5,000,000
<br />UMBRELLA LIAB
<br />EACH OCCURRENCE$
<br />OCCUR
<br />5,000,000
<br />EXCESS LIAB
<br />CLAIMS-MADEAGGREGATE$
<br />A UHF917904600 09/01/1209/01/13
<br />$
<br />DEDUCTIBLE
<br />XNONE
<br />$
<br />RETENTION$
<br />WC STATU-OTH-
<br />X
<br />WORKERS COMPENSATION
<br />TORY LIMITSER
<br />AND EMPLOYERS' LIABILITY
<br />Y / N
<br />C57WELQ0689 09/01/1209/01/131,000,000
<br />ANY PROPRIETOR/PARTNER/EXECUTIVE
<br />E.L. EACH ACCIDENT$
<br />N / A
<br />OFFICER/MEMBER EXCLUDED?
<br />1,000,000
<br />(Mandatory in NH)
<br />E.L. DISEASE - EA EMPLOYEE$
<br />If yes, describe under
<br />1,000,000
<br />E.L. DISEASE - POLICY LIMIT$
<br />DESCRIPTION OF OPERATIONS below
<br />B Prof Liab - E&O09/01/1209/01/13Occ/Agg5,000,000
<br />LHR819181
<br />E&O (Claims Made)RETRO DATE 9/1/1995 Ded.5,000
<br />DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required)
<br />The City of Riverside, and its officers, employees and agents are added as
<br />additional insured for work done by the named insured on Project: 3500,
<br />Riverside Utilities. General Liability Insurance policy automatically
<br />extends blanket additional insured when requested by written contract.
<br />Waiver of Subrogation included per policy form.
<br />CERTIFICATE HOLDERCANCELLATION
<br />CITYOFR
<br />SHOULDANYOFTHEABOVEDESCRIBEDPOLICIESBECANCELLEDBEFORE
<br />THEEXPIRATIONDATETHEREOF,NOTICEWILLBEDELIVEREDIN
<br />City of Riverside
<br />ACCORDANCE WITH THE POLICY PROVISIONS.
<br />Riverside Public Utilities
<br />Department, Energy Delivery
<br />AUTHORIZED REPRESENTATIVE
<br />Division, 3750 University Ave.
<br />3rd Floor, Riverside, CA 92501
<br />© 1988-2009 ACORD CORPORATION. All rights reserved.
<br />ACORD 25 (2009/09)The ACORD name and logo are registered marks of ACORD
<br />
|