ANY PROPRIETOR/PARTNER/EXECUTIVE
OFFICER/MEMBER EXCLUDED?
INSR ADDL SUBR
LTR INSD WVD
PRODUCER CONTACT
NAME:
FAXPHONE
(A/C, No):(A/C, No, Ext):
E-MAIL
ADDRESS:
INSURER A :
INSURED INSURER B :
INSURER C :
INSURER D :
INSURER E :
INSURER F :
POLICY NUMBER POLICY EFF POLICY EXPTYPE OF INSURANCE LIMITS(MM/DD/YYYY) (MM/DD/YYYY)
AUTOMOBILE LIABILITY
UMBRELLA LIAB
EXCESS LIAB
WORKERS COMPENSATION
AND EMPLOYERS' LIABILITY
AUTHORIZED REPRESENTATIVE
EACH OCCURRENCE $
DAMAGE TO RENTEDCLAIMS-MADE OCCUR $PREMISES (Ea occurrence) MED EXP (Any one person) $
PERSONAL & ADV INJURY $
GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $
PRO-POLICY LOC PRODUCTS - COMP/OP AGGJECT
OTHER: $
COMBINED SINGLE LIMIT
$(Ea accident)
ANY AUTO BODILY INJURY (Per person) $
OWNED SCHEDULED
BODILY INJURY (Per accident) $AUTOS ONLY AUTOS
HIRED NON-OWNED PROPERTY DAMAGE
$AUTOS ONLY AUTOS ONLY (Per accident)
$
OCCUR EACH OCCURRENCE
CLAIMS-MADE AGGREGATE $
DED RETENTION $
PER OTH-
STATUTE ER
E.L. EACH ACCIDENT
E.L. DISEASE - EA EMPLOYEE $
If yes, describe under
E.L. DISEASE - POLICY LIMITDESCRIPTION OF OPERATIONS below INSURER(S) AFFORDING COVERAGE NAIC #
COMMERCIAL GENERAL LIABILITY
Y / N
N / A
(Mandatory in NH)
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS.
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.
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 have ADDITIONAL INSURED provisions or 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).
COVERAGES CERTIFICATE NUMBER: REVISION NUMBER:
CERTIFICATE HOLDER CANCELLATION
© 1988-2015 ACORD CORPORATION. All rights reserved.ACORD 25 (2016/03)
CERTIFICATE OF LIABILITY INSURANCE
DATE (MM/DD/YYYY)
$
$
$
$
$
The ACORD name and logo are registered marks of ACORD
10/7/2022
License # 0E67768
(925) 416-7862
13056
Macks Craic, Inc. dba Mack5
1000 Broadway, Suite 260
Oakland, CA 94607
29599
A 1,000,000
X X PSB0001139 7/1/2022 7/1/2023 1,000,000
10,000
1,000,000
2,000,000
2,000,000
1,000,000A
PSA0001031 7/1/2022 7/1/2023
2,000,000A
PSE0001054 7/1/2022 7/1/2023 2,000,000
A
X PSW0001114 7/1/2022 7/1/2023 1,000,000
1,000,000
1,000,000
B Professional Liab. USS2232786 4/10/2022 Per Claim 2,000,000 B Professional Liab. USS2232786 4/10/2022 4/10/2023 Aggregate 2,000,000 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) RE: Shields-Reid Park – 22789
All operations of the Named Insured including project referenced above.
General Liability: The City of Richmond, its officers, officials, employees, agents and volunteers are included as Additional Insured on Primary & Non- Contributory basis with Waiver of Subrogation included, as required by written contract.
Workers' Compensation: Waiver of Subrogation is in favor of The City of Richmond, its officers, officials, employees, agents and volunteers, as required by written contract.
Auto Liability: The City of Richmond, its officers, officials, employees, agents and volunteers are included as Additional Insured with Waiver of Subrogation SEE ATTACHED ACORD 101
City of Richmond
450 Civic Center Plaza
Richmond, CA 94804-0046
MACKCRA-01 SUMMANR
IOA Insurance Services
3875 Hopyard Road
Suite 200
Pleasanton, CA 94588
Rita Summan
[email protected]
RLI Insurance Company
U.S. Specialty Insurance Company
X
4/10/2023
X
X
X
X X
X
X
FORM NUMBER:
EFFECTIVE DATE:
The ACORD name and logo are registered marks of ACORD
ADDITIONAL REMARKS
ADDITIONAL REMARKS SCHEDULE
FORM TITLE:
Page of
THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, ACORD 101 (2008/01)
AGENCY CUSTOMER ID:LOC #:
AGENCY NAMED INSUREDPOLICY NUMBERCARRIER NAIC CODE
© 2008 ACORD CORPORATION. All rights reserved.
IOA Insurance Services
MACKCRA-01
SEE PAGE 1
1 SEE PAGE 1ACORD 25Certificate of Liability Insurance
License # 0E677681
SEE P 1Macks Craic, Inc. dba Mack51000 Broadway, Suite 260Oakland, CA 94607SEE PAGE 1 SUMMANR1
Description of Operations/Locations/Vehicles:included, as required by written contract.Excess Liability follows form over the General Liability, Auto Liability and Employers Liability.30-Day Notice of Cancellation is included per policy provisions.