CERTIFICATE HOLDER
© 1988-2010 ACORD CORPORATION. All rights reserved.
ACORD 25 (2010/05)
AUTHORIZED REPRESENTATIVE
CANCELLATION
DATE (MM/DD/YYYY)
CERTIFICATE OF LIABILITY INSURANCE
LOCJECT
PRO-POLICY
GEN'L AGGREGATE LIMIT APPLIES PER:
OCCURCLAIMS-MADE
COMMERCIAL GENERAL LIABILITY
GENERAL LIABILITY
PREMISES (Ea occurrence) $
DAMAGE TO RENTED
EACH OCCURRENCE $
MED EXP (Any one person) $
PERSONAL & ADV INJURY $
GENERAL AGGREGATE $
PRODUCTS - COMP/OP AGG $
$RETENTIONDED
CLAIMS-MADE
OCCUR
$
AGGREGATE $
EACH OCCURRENCE $UMBRELLA LIAB
EXCESS LIAB
DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required) INSR
LTR TYPE OF INSURANCE POLICY NUMBER
POLICY EFF
(MM/DD/YYYY)
POLICY EXP
(MM/DD/YYYY) LIMITS
WC STATU-
TORY LIMITS
OTH-
ER
E.L. EACH ACCIDENT
E.L. DISEASE - EA EMPLOYEE
E.L. DISEASE - POLICY LIMIT
$
$
$
ANY PROPRIETOR/PARTNER/EXECUTIVE
If yes, describe under
DESCRIPTION OF OPERATIONS below
(Mandatory in NH)
OFFICER/MEMBER EXCLUDED?
WORKERS COMPENSATION
AND EMPLOYERS' LIABILITY Y / N
AUTOMOBILE LIABILITY
ANY AUTO
ALL OWNED SCHEDULED
HIRED AUTOS
NON-OWNED
AUTOS AUTOS
AUTOS
COMBINED SINGLE LIMIT
BODILY INJURY (Per person)
BODILY INJURY (Per accident)
PROPERTY DAMAGE $
$
$
$
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
ADDL
WVD
SUBR
N / A
$
$
(Ea accident)
(Per accident)
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).
The ACORD name and logo are registered marks of ACORD
COVERAGES CERTIFICATE NUMBER: REVISION NUMBER:
INSURED
PHONE
(A/C, No, Ext):
PRODUCER
ADDRESS:
E-MAIL
FAX
(A/C, No):
CONTACT
NAME:
NAIC #
INSURER A :
INSURER B :
INSURER C :
INSURER D :
INSURER E :
INSURER F :
INSURER(S) AFFORDING COVERAGE
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS.
ALKEME Insurance
TDW Risk Management Associates
111 Corporate Dr. #200
Ladera Ranch CA 92694
Melissa Lauer
(949)620-6862
[email protected]
License#: 0M55604
Homeland Insurance Company of New York
34452
IQPERSO-01
Intact Insurance Specialty Solutions
IQ Personnel, Inc.
8039 Painter Ave., Ste 200
Whittier CA 90602
United Wisconsin Insurance Company
29157
1216197000
B
X
1,000,000
50,000
X
1,000,000
5,000,000
2,000,000
793-01-43-15-0000
7/13/2025
7/13/2026
X
Y
Y
5,000
A
X
4,000,000
4,000,000
7930143160000
7/13/2025
7/13/2026
X
C
Y
WC026-00064-024
9/30/2025
9/30/2026
1,000,000
1,000,000
1,000,000
B
Contractors Pollution Liab
11/21/2025
X
793-01-43-15-0000
7/13/2025
7/13/2026
Each Pollution Condit
Deductible
$1,000,000
$5,000
Contractors Environmental Liability Coverage Part
(Each Pollution Condition)
Contractors Pollution Liability $1,000,000 $5,000 Each Pollution Condition Transportation Pollution Liability $1,000,000 $5,000 Each Pollution Condition Non-Owned Disposal Site Liability (Claims-Made) $1,000,000 $5,000 Each Pollution Condition Professional Liability Insurance $1,000000 Limit Per Claim, $2,000,000 Aggregate Limit, April 13, 2005 Retroactive Date. The $5,000,000 Commercial Excess Liability applies to this coverage.
Pollution Liability Insurance $1,000,000 Limit Per Claim, $2,000,000 Aggregate Limit, April 13, 2005 Retroactive Date.
See Attached...
City of Glendale - Risk Management
Attn: Veronika Padron
613 E. Broadway #100
Glendale CA 91206
ACORD 101 (2008/01)
The ACORD name and logo are registered marks of ACORD
© 2008 ACORD CORPORATION. All rights reserved.
THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, FORM NUMBER: FORM TITLE:
ADDITIONAL REMARKS
ADDITIONAL REMARKS SCHEDULE Page of
AGENCY CUSTOMER ID:
LOC #:
AGENCY
CARRIER NAIC CODE
POLICY NUMBER
NAMED INSURED
EFFECTIVE DATE:
IQPERSO-01
1 1
ALKEME Insurance
IQ Personnel, Inc.
8039 Painter Ave., Ste 200
Whittier CA 90602
25 CERTIFICATE OF LIABILITY INSURANCE
The City of Glendale, its officers, agents, employees and volunteers are included as additional insureds as respects General Liability coverage, per the attached endorsement as per written contract. Coverage is primary and non-contributory per the attached endorsement respects General Liability coverage as per written contract. Waiver of subrogation applies as respects General Liability coverage per the attached endorsement as per written contract. *Please note Copyright Laws apply to the Acord form prohibiting us from modifying the cancellation clause. However, per TDW Risk Management Associates, LLC procedures we will notify you within 30 days if said policy cancels for any reason other than non-payment. In the event that the policies cancel for non-payment, you will be notified within 10 days.