[Rev:11/14/2016]
PURCHASE AGREEMENT BETWEEN THE
CITY OF SOUTH SAN FRANCISCO AND THE SWENSON GROUP
These terms and conditions govern the purchase of materials, supplies, and/or equipment, including any related installation, training, and/or minor services and repairs described in this Purchase Agreement (“Purchase Agreement”) by The Swenson Group (“Vendor”) for the City of South San Francisco (“City”). Vendor and City are collectively referred to in this Purchase Agreement as “the Parties.” If the Vendor selects subcontractors to execute a portion the terms of this Purchase Agreement, that subcontractor is an agent of the Vendor, and is hereby included by reference as “the Vendor.”
1. Time of Performance. This Purchase Agreement shall commence effective May 10, 2024, and shall end when Vendor has provided to the City the Products and Services described in this Purchase Agreement, and in Exhibit A (“Products” and/or “Services”). The equipment and products listed in Exhibit A must be delivered July 31, 2024. The installation set forth in Exhibit A must be completed by July 31, 2024. The maintenance services set forth in Exhibit A shall be completed by June 30, 2029. In the event that any of the terms of Exhibit A conflict with this Purchase Agreement, the terms of the Purchase Agreement shall prevail.
2. Description of Goods. Vendor shall perform everything required to be performed and shall provide and furnish to City with 18 replacement copiers, 2 additional copiers and maintenance services for all City copiers for five years as described in Exhibit A and shall complete delivery F.O.B. to the City of South San Francisco on or before 90 days from the date of this Purchase Agreement in strict accordance with the specifications as established by this Purchase Agreement and Exhibit(s), which specifications are incorporated herein and made part of this Purchase Agreement.
3. Description of Purchase. The City hereby agrees to pay Vendor for the Products and/or Services with a not to exceed amount. The total compensation for Products and/or Services performed under this Purchase Agreement is not to exceed Four Hundred Forty-Eight Thousand Five Hundred Forty-Nine Dollars and Twenty-Six Cents ($448,549.26). Vendor shall invoice the City $151,249.26 upon delivery and installation of purchased copiers.
Maintenance Services shall be invoiced monthly at $4,955 per month for 60 months. Annual cost to the City for Maintenance Services annually as follows: $59,460 FY 2024-2025, $59,460 FY 2025-2026, $59,460 FY 2026-2027, $59,460 FY 2027-2028, $59,460 FY 2028-2029.
The City shall pay Vendor invoices for Products and/or Services actually delivered in accordance with this Purchase Agreement. To be eligible for payment, Vendor invoices must itemize the Products and/or Services delivered and the corresponding prices in accordance with this Purchase Agreement. Payment of Vendor invoices does not constitute acceptance of Products and/or Services delivered. Prices of Products and/or Services delivered that are not in accordance with this Purchase Agreement are subject to adjustment. In no event will the prices of Products and/or Services delivered exceed that specified on this Purchase Agreement. Payments shall be subject to adjustment for defects in quality or failure of Vendor to meet terms and conditions herein and in Exhibit A. Such adjustments shall be equal to one hundred percent (100%) of City’s costs to correct such defects or Vendor’s failure to meet Purchase Agreement requirements.
4. Taxes. Vendor shall pay all applicable federal, state and local taxes, which may be chargeable against the delivery of the Products and/or Services listed herein.
5. General Warranties and Product Compliance. Vendor warrants that: (A) All Products and/or Services are as described on this Purchase Agreement conform to all drawings, samples, descriptions and specifications contained in Exhibit A; (B) All Products and/or Services delivered are new and of good merchantable quality, free from material defects of workmanship and fit for the purpose for which sold or provided; (C) Vendor has good title to all Products delivered and all Products delivered are free from liens and other encumbrances; and (D) Vendor's delivery and installation of the Products and/or Services will be in strict conformity with all applicable local, state, and federal laws. For purposes of this warranty, any Products or components not meeting the foregoing quality shall be deemed defective. The foregoing warranty provisions shall also be applicable to equipment or materials provided by a third-party entity to Vendor via this Purchase Agreement.
Vendor also expressly warrants and guarantees, for three years that the Products and/or Services furnished by it to City shall be free from breakage or defects of material and workmanship under normal use, service and maintenance from the date of acceptance of the City, and expressly agrees to repair or replace Products and/or Services or any part thereof which proves defective as a result of inferior or defective materials, equipment or workmanship. If within the period stated above, any repairs or replacements in connection with the Products and/or Services are, in the opinion of the City, rendered necessary as a result of the use of inferior or defective materials, equipment or workmanship, Vendor agrees on receipt of notice from City and without expense to the City, for freight, parts or labor, to properly repair, replace or correct any and all such defects therein. If Vendor, after such notice, fails to proceed promptly with the terms
[Rev:11/14/2016]
of this warranty and guarantee, the City may perform the work necessary to effectuate such corrections, repairs and replacements, and recover the cost thereof from Vendor.
6. Damage to City Facilities. Damage to City or public facilities or private property caused by the Vendor or by its subcontractors during delivery or installation shall be repaired and/or replaced in kind at no cost to the City.
7. Site Safety and Cleanup. The delivery and installation site shall be kept clean and free of hazards at all times during installation. After installation is completed at the site, Vendor shall clean the surrounding area to the condition prior to installation.
8. Final Inspection and Work Acceptance. Finished installation work and/or equipment shall be subject to final inspection and acceptance or rejection by the City.
9. Indemnity. To the fullest extent permitted by law, Vendor shall indemnify, defend (with counsel acceptable to the City), and hold harmless the City and its elected and appointed officers, officials, employees, agents, contractors and consultants (collectively, the “City Indemnitees”) from and against any and all liability, loss, damage, claims, expenses and costs (including, without limitation, attorneys’ fees and costs of litigation) (collectively, “Liability”) of every nature arising out of or in connection with the delivery and installation of the Products and/or Services described on this Purchase Agreement or Vendor’s failure to comply with this Purchase Agreement, except such Liability caused by the gross negligence or willful misconduct of the City Indemnitees.
10. Insurance. Before beginning any installation work and continuing throughout the term of this Purchase Agreement, Vendor, at its sole cost and expense, furnish the City with certificates of insurance evidencing that Contractor has obtained and maintains insurance in the following amounts:
A. Workers’ Compensation that satisfies the minimum statutory limits.
B. Commercial General Liability and Property Damage Insurance in an amount not less than ONE MILLION DOLLARS ($1,000,000) combined single limit per occurrence, TWO MILLION DOLLARS ($2,000,000) annual aggregate, for bodily injury, property damage, products, completed operations and contractual liability coverage. The policy shall also include coverage for liability arising out of the use and operation of any City-owned or City-furnished equipment used or operated by the Vendor, its personnel, agents or subcontractors.
C. Comprehensive automobile insurance in an amount not less than ONE MILLION DOLLARS ($1,000,000) per occurrence for bodily injury and property damage including coverage for owned and non-owned vehicles.
All insurance policies shall be written on an occurrence basis and shall name the City Indemnitees as additional insureds with any City insurance shall be secondary and in excess to Vendor’s insurance. If the Vendor’s insurance policy includes a self-insured retention that must be paid by a named insured as a precondition of the insurer’s liability, or which has the effect of providing that payments of the self-insured retention by others, including additional insureds or insurers do not serve to satisfy the self-insured retention, such provisions must be modified by special endorsement so as to not apply to the additional insured coverage required by this agreement so as to not prevent any of the parties to this agreement from satisfying or paying the self-insured retention required to be paid as a precondition to the insurer’s liability. Additionally, the certificates of insurance must note whether the policy does or does not include any selfinsured retention and also must disclose the deductible.
The City Risk Manager, in writing, may approve a variation in the foregoing insurance requirements. A valid and executed approval by Risk Manager must accompany this Purchase Agreement for a variation to be binding.
11. Prevailing Wage. Where applicable, the wages to be paid for a day's work to all classes of laborers, workmen, or mechanics on the work contemplated by this Purchase Agreement, shall be not less than the prevailing rate for a day’s work in the same trade or occupation in the locality within the state where the work hereby contemplates to be performed as determined by the Director of Industrial Relations pursuant to the Director’s authority under Labor Code Section 1770, et seq. Each laborer, worker or mechanic employed by Vendor or by any subcontractor shall receive the wages herein provided for. The Vendor shall pay two hundred dollars ($200), or whatever amount may be set by Labor Code Section 1775, as may be amended, per day penalty for each worker paid less than prevailing rate of per diem wages. The difference between the prevailing rate of per diem wages and the wage paid to each worker shall be paid by the Vendor to each worker.
[Rev:11/14/2016]
An error on the part of an awarding body does not relieve the Vendor from responsibility for payment of the prevailing rate of per diem wages and penalties pursuant to Labor Code Sections 1770-1775. The City will not recognize any claim for additional compensation because of the payment by the Vendor for any wage rate in excess of prevailing wage rate set forth. The possibility of wage increases is one of the elements to be considered by the Vendor.
A. Posting of Schedule of Prevailing Wage Rates and Deductions. If the schedule of prevailing wage rates is not attached hereto pursuant to Labor Code Section 1773.2, the Vendor shall post at appropriate conspicuous points at the site of the project a schedule showing all determined prevailing wage rates for the various classes of laborers and mechanics to be engaged in work on the project under this contract and all deductions, if any, required by law to be made from unpaid wages actually earned by the laborers and mechanics so engaged.
B. Payroll Records. Each Vendor and subcontractor shall keep an accurate payroll record, showing the name, address, social security number, work week, and the actual per diem wages paid to each journeyman, apprentice, worker, or other employee employed by the Vendor in connection with the public work. Such records shall be certified and submitted weekly as required by Labor Code Section 1776.
12. Payment of Employment Taxes; Tax Withholding. Vendor is solely responsible for the payment of employment taxes incurred under this Agreement and any similar federal or state taxes. To be exempt from tax withholding, Vendor must provide City with a valid California Franchise Tax Board form 590 (“Form 590”), as may be amended and such Form 590 shall be attached hereto and incorporated herein as Exhibit B. Unless Vendor provides City with a valid Form 590 or other valid, written evidence of an exemption or waiver from withholding, City may withhold California taxes from payments to Vendor as required by law. Vendor shall obtain and maintain on file for three (3) years after the termination of this Agreement, Form 590s (or other written evidence of exemptions or waivers) from all subcontractors.
Vendor accepts sole responsibility for withholding taxes from any non-California resident subcontractor and shall submit written documentation of compliance with Vendor’s withholding duty to City upon request.
13. Termination. In addition to all other legal and equitable rights of the City, the City may terminate this Purchase Agreement upon notice to the Vendor. If the City terminates this Purchase Agreement, the City will pay the Vendor for Products and/or Services accepted in accordance with this Purchase Agreement prior to the date of termination.
14. Prevailing Party. In the event that either party to this Purchase Agreement commences any legal action or proceeding (including but not limited to arbitration) to interpret the terms of this Purchase Agreement, the prevailing party in such a proceeding shall be entitled to recover its reasonable attorney’s fees associated with that legal action or proceeding.
15. Notice. All notices and other communications which are required or may be given under this Agreement shall be in writing and shall be deemed to have been duly given (i) when received if personally delivered; (ii) when received if transmitted by telecopy, if received during normal business hours on a business day (or if not, the next business day after delivery) provided that such facsimile is legible and that at the time such facsimile is sent the sending Party receives written confirmation of receipt; (iii) if sent for next day delivery to a domestic address by recognized overnight delivery service (e.g., Federal Express); and (iv) upon receipt, if sent by certified or registered mail, return receipt requested. In each case notice shall be sent to the respective Parties as follows:
Vendor: The Swenson Group
1410 Stealth Street
Livermore, CA 94551
City:
City Clerk
City of South San Francisco
400 Grand Avenue
South San Francisco, CA 94080
16. Assignment, Governing Law. The Vendor may not assign any of Vendor's obligations under this Purchase Agreement without the City’s prior written approval. This Purchase Agreement is governed by California law. The jurisdiction for any litigation arising from this Purchase Agreement shall be in the state of California and shall be venued in the County of San Mateo.
17. Severability. If any portion of this Purchase Agreement is held invalid, the Parties agree that such invalidity shall not affect the validity of the remaining portions of this Purchase Agreement.
[Rev:11/14/2016]
18. Entire Agreement. This Agreement represents the entire and integrated agreement between the Parties. This Purchase Agreement may be modified or amended only by a subsequent written agreement signed by both Parties.
19. Execution in Counterpart. This Agreement may be executed in counterparts and/or by facsimile or other electronic means, and when each Party has signed and delivered at least one such counterpart, each counterpart shall be deemed an original, and, when taken together with other signed counterpart, shall constitute one Agreement, which shall be binding upon and effective as to all Parties.
CITY OF SOUTH SAN FRANCISCO VENDOR
A Municipal Corporation
By:___________________________ By:___________________________ Sharon Ranals, City Manager
Name: ________________________
Approved as to Form: Title: _________________________
Company: _____________________
__________________________ Date: _________________________ City Attorney
2729963.1
City of SSF Quote
18 Unit Replacement & 2 Additional Units
Equipment Address Equipment location Equip #
Current
Model
Current
Accessories
Proposed Model Proposed Model Description Unit Subtotal Total w/Tax 550 North Canal Public Works & Parks 47098v C458
PC-415, FK-514, FS-536,
PK-520
C450i bizhub C450i 45 ppm color MFP
C450i PC-416 PAPER FEED CABINET
C450i
FS-539 SD (50- sheet floor staple finisher plus
saddle stitch and manual stapler)
C450i RU-513 FINISHER RELAY UNIT
C450i PK-524 2/3-Hole Punch Kit $ 8,002.12 $ 8,792.33
601 Grand Avenue Magnolia Center 3rd Floor 47099v C227 DK-514,FS-533 C250i bizhub C250i + DF-714
C250i PC-216 PAPER FEED CABINET
C250i FS-536SD Finisher
C250i RU-513 FINISHER RELAY UNIT $ 5,931.02 $ 6,516.71
195 Belle Aire Road WQCP Library Admin Bldg, Downstairs 47105v BH227 DK-513X, FK-513, FS-534
C250i bizhub C250i + DF-714
C250i DK-516 Enhanced Copy Desk (Storage only)
C250i FS-536 Finisher (50 Sheets)
C250i RU-513 FINISHER RELAY UNIT $ 4,661.12 $ 5,121.41
Exhibit A
Equipment Address Equipment location Equip #
Current
Model
Current
Accessories
400 Grand Avenue City Hall - First Main Floor. Machine is Across the economic dev. & housing. 47110v C308 PC-410, FS-534, PK-520
C250i bizhub C250i + DF-714
C250i PC-416 PAPER FEED CABINET
C250i FS-536 Finisher (50 Sheets)
C250i RU-513 FINISHER RELAY UNIT
C250i PK-524 2/3-Hole Punch Kit 5,250.66 $ 5,769.16 $
1 Chestnut Ave Police Administration 1st Floor on the right 47114v C558 PC-415, FS-536, PK-520
C550i bizhub C550i 55 ppm color MFP
C550i PC-416 PAPER FEED CABINET
C550i
FS-539 (50- sheet floor staple finisher plus
manual stapler)
C550i RU-513 FINISHER RELAY UNIT
C550i PK-524 2/3-Hole Punch Kit
C550i IC-420 Image Controller
C550i VI-516 Video Interface Kit 11,154.84 $ 12,256.38 $ 315 Maple Avenue Engineering 47116v C558
PC-415, FK-514, FS-537,
PK-523
C550i bizhub C550i 55 ppm color MFP
C550i PC-416 PAPER FEED CABINET
C550i FS-540 100-SHEET STAPLE FINISHER
C550i RU-513 FINISHER RELAY UNIT
C550i PK-526 2/3 Hole Punch Kit 9,783.51 $ 10,749.63 $
Equipment Address Equipment location Equip #
Current
Model
Current
Accessories
315 Maple Avenue Planning Division 47136v C658
PC-415, LU-302, FK-514,
FS-537, PK-523
C550i bizhub C550i 55 ppm color MFP
C550i PC-416 PAPER FEED CABINET
C550i
LU-302 Large Capacity Unit (3,000 sheets/Letter
size only)
C550i FS-540 SD 100-SHEET BOOKLET FINISHER
C550i RU-513 FINISHER RELAY UNIT
C550i PK-526 2/3 Hole Punch Kit 10,916.41 $ 11,994.41 $ 400 Grand Avenue City Clerk's Office, 1st Floor 47148v C368 PC-410, FK-514, FS-534,
PK-520
C450i bizhub C450i 45 ppm color MFP
C450i PC-416 PAPER FEED CABINET
C450i
FS-539 (50- sheet floor staple finisher plus
manual stapler)
C450i RU-513 FINISHER RELAY UNIT
C450i PK-524 2/3-Hole Punch Kit 7,553.27 $ 8,299.16 $
480 North Canal Fire Station 47198v C458
PC-415, FK-514, FS-536,
PK-520
C450i bizhub C450i 45 ppm color MFP
C450i PC-416 PAPER FEED CABINET
C450i
FS-539 (50- sheet floor staple finisher plus
manual stapler)
C450i RU-513 FINISHER RELAY UNIT
C450i PK-524 2/3-Hole Punch Kit 7,553.27 $ 8,299.16 $
Equipment Address Equipment location Equip #
Current
Model
Current
Accessories
400 Grand Avenue City Hall, Top Floor 47201v C458
PC-415, FS-536, PK-520
C450i bizhub C450i 45 ppm color MFP
C450i PC-416 PAPER FEED CABINET
C450i
FS-539 (50- sheet floor staple finisher plus
manual stapler)
C450i RU-513 FINISHER RELAY UNIT
C450i PK-524 2/3-Hole Punch Kit
C450i IC-420 Image Controller
C450i VI-516 Video Interface Kit 9,776.92 $ 10,742.39 $ 781 Tennis Drive Fernekes Bldng 47222v C458
PC-415, FK-514, FS-536,
PK-520
C650i bizhub C650i 65 ppm color MFP
C650i PC-416 PAPER FEED CABINET
C650i
FS-539 (50- sheet floor staple finisher plus
manual stapler)
C650i RU-513 FINISHER RELAY UNIT
C650i PK-524 2/3-Hole Punch Kit 9,590.69 $ 10,537.77 $
520 Tamarack Lane Computer Learning Center 47804v C258
DK-510, FK-514, FS-534
C450i bizhub C450i 45 ppm color MFP
C450i PC-416 PAPER FEED CABINET
C450i
FS-539 (50- sheet floor staple finisher plus
manual stapler)
C450i RU-513 FINISHER RELAY UNIT 7,368.82 $ 8,096.49 $
Equipment Address Equipment location Equip #
Current
Model
Current
Accessories
195 Belle Aire Road WQCP Maintenance Building / (Downstairs) 47806v C368 DK-510, FK-514 C360i bizhub C360i + DF-714
C360i DK-516 Enhanced Copy Desk (Storage only) 5,401.78 $ 5,935.21 $ C360i
FS-539 (50- sheet floor staple finisher plus
manual stapler)
C360i RU-513 FINISHER RELAY UNIT
400 Grand Avenue Finance Department / Basement 47810v C458 PC-415, FS-537, PK-523
C650i bizhub C650i 65 ppm color MFP
C650i PC-416 PAPER FEED CABINET
C650i FS-540 100-SHEET STAPLE FINISHER
C650i RU-513 FINISHER RELAY UNIT
C650i PK-526 2/3 Hole Punch Kit 10,443.01 $ 11,474.26 $ 195 Belle Aire Road Waste Treatment Works Building 2nd flr 47812v C558 PC-415, FK-514, FS-536
C250i bizhub C250i + DF-714
C250i PC-416 PAPER FEED CABINET
C250i
FS-539 SD (50- sheet floor staple finisher plus
saddle stitch and manual stapler)
C250i RU-513 FINISHER RELAY UNIT 5,089.73 $ 5,592.34 $
480 North Canal Fire Station/Upstairs 48470vr BH227 DK-513X C250i bizhub C250i + DF-714
C250i DK-516 Enhanced Copy Desk (Storage only) 3,550.24 $ 3,900.83 $
Equipment Address Equipment location Equip #
Current
Model
Current
Accessories
2380 Galway Dr Expansion - Wesborough Preschool
C250i bizhub C250i + DF-714
C250i PC-216 PAPER FEED CABINET
C250i
FS-539 (50- sheet floor staple finisher plus
manual stapler)
C250i RU-513 FINISHER RELAY UNIT
C250i PK-524 2/3-Hole Punch Kit 4,751.59 $ 5,220.81 $
306 Walnut Avenue Expansion - Grand Library Public Access C3350i bizhub C3350i 35 ppm color MFP A4 only
C3350i DK-P05 Copy Desk Stand
C3350i PF-P21 Paper Feed Unit
C3350i PF-P21 Paper Feed Unit 2,690.79 $ 2,956.51 $
306 Walnut Avenue Grand Library 48471vr C258
DK-510
FS-534
C250i bizhub C250i + DF-714
C250i FS-533 Inner Finisher
C250i DK-516 Enhanced Copy Desk (Storage only) 4,092.97 $ 4,497.15 $ 510 Elm Court Siebecker Preschool 48473vr C258
DK-510
FS-533
C250i bizhub C250i + DF-714
C250i DK-516 Enhanced Copy Desk (Storage only)
C250i FS-533 Finisher (50-sheet inner staple finisher) 4,092.97 $ 4,497.15 $ $ 151,249.26 137,655.73 $
Sub-Total Sub-Total
w/o Tax w/ Tax (9.875%)
Address Equipment location Equip# Model Year 1 Year 2 Year 3 Year 4 Year 5 Total 550 North Canal Public Works & Parks TBD C450i
601 Grand Avenue Teglia Center 3rd Floor TBD C250i
195 Belle Aire Road WQCP Library Admin Bldg, Downstairs TBD C250i 400 Grand Avenue City Hall - First Floor TBD C250i
1 Chestnut Ave Police Administration - 1st Floor TBD C550i 315 Maple Avenue Engineering TBD C550i
315 Maple Ave Planning Division TBD C550i
400 Grand Avenue City Clerk's Office - 1st Floor TBD C450i 480 North Canal Fire Station TBD C450i
400 Grand Avenue City Hall - Top Floor TBD C450i
781 Tennis Drive Fernekes Bldng TBD C650i
520 Tamarack Lane Computer Learning Center TBD C450i
195 Belle Aire Road WQCP Maintenance Building - (Downstairs) TBD C360i 400 Grand Avenue Finance Department / Basement TBD C650i 195 Belle Aire Road Waste Water Treatment Plant - 2nd flr. TBD C250i 480 North Canal Fire Station/Upstairs/Replace 43317 TBD C250i New Westborough Preschool TBD C250i
New Grand Library Public Access TBD C3350i
306 Walnut Avenue Grand Library/Replace 43318 TBD C250i 601 Grand Avenue Senior Center/Replace 43320 48472vr C258 510 Elm Court Siebecker Preschool TBD C250i
1121 South San Francisco Drive Terra Bay Gym/Replace 43319 48474vr C258 480 North Canal Fire Administration Back up - EOC Bldg. 47807v C258 329 Miller Avenue IT Dept Main Office 47809v C258
1 Chestnut Avenue Police 48496vr BH227
1 Chestnut Avenue Police - 2nd Floor Admin dept. 49979vr C550i P.O. Box 711 400 Grand Avenu 366 Grand 50534vr BH360i
366 Grand Avenu EAC 50778vr C300i
Parks & Rec - 901 Civic Campus Way 3rd flr. 3rd floor - Park & Rec Admin 51487vr C550i Parks & Rec - 901 Civic Campus Way 3rd flr. 3rd floor Main Library Admin area 51490vr C550i Parks & Rec - 901 Civic Campus Way 3rd flr. 1st floor City Clerk 51732vr C360i Parks & Rec - 901 Civic Campus Way 3rd flr. 3rd Floor Librry - Public/Admin 51853vr C3350i $ 297,300.00
City of SSF Service - Summary for 5 Years @ $4,955.00/month $ 59,460.00 59,460.00 $ 59,460.00 $ 59,460.00 $ 59,460.00 $
This agreement contract covers unlimited Preventative Maintenance and intervening service calls up to 100,000 B&W and 85,000 Color per month, during normal working hours 8:00 a.m. to 5:00 p.m. Monday through Friday, except holidays, includes all parts and labor, and excludes all other consumable supply items (e.g. paper, staples, etc..), unless specifically listed below. Additional impressions over the monthly allowance will be billed at $0.0079 B/W and $0.049 Color. This contract does not cover shop overhauls and/or reconditions of equipment, after hour service, abuse or misuse by customer neglect, fire, flood, acts of nature or repairs made necessary by service performed other than by TSG or its authorized representative. On previously installed equipment, or after this agreement’s initial term, main boards, also known as “mother boards” are not covered. If service is required due to use of non-approved supplies, customer agrees to pay any additional service charges that may be incurred due to inferior or foreign supply products. Unless specified above, this contract does not cover print controllers on digital products connected to a network. If this product is networked, terms & conditions of the Network Information Sheet apply to this agreement.
This agreement is non-cancelable. Customer agrees to pay all base charges and overages (if any) for the period described above. This contract is nontransferable and is automatically renewed for a period of one year once the amount of time specified has been exceeded unless the customer furnishes TSG with ninety (90) days advance written notification of their desire to cancel this agreement. Applicable sales tax will be applied.
If a collection matter occurs, customer agrees to pay court costs and any reasonable attorneys fees. Interest will be charged at 1 ½ % per month after thirty (30) days on any unpaid balance. TSG reserves the right to withhold service or cancel this Agreement if a customer’s account is over sixty (60) days delinquent or if the equipment becomes unserviceable for any reason. If TSG should choose to cancel this Agreement, any unearned maintenance fees will be applied to the customers account. No one is authorized to change, alter or amend the terms or conditions of this Agreement unless agreed to in writing by both parties.
7061213 Form 590 2020
TAXABLE YEAR
2021 Withholding Exemption Certificate
CALIFORNIA FORM
590
The payee completes this form and submits it to the withholding agent. The withholding agent keeps this form with their records.
Withholding Agent Information
Name
Name □ SSN or ITIN □ FEIN □ CA Corp no. □ CA SOS file no.
Address (apt./ste., room, PO box, or PMB no.)
City (If you have a foreign address, see instructions.) State ZIP code Exemption Reason
Check only one box.
By checking the appropriate box below, the payee certifies the reason for the exemption from the California income tax withholding requirements on payment(s) made to the entity or individual.
CERTIFICATE OF PAYEE: Payee must complete and sign below.
To learn about your privacy rights, how we may use your information, and the consequences for not providing the requested information, go to ftb.ca.gov/forms and search for 1131. To request this notice by mail, call 800.852.5711.
Under penalties of perjury, I declare that I have examined the information on this form, including accompanying schedules and statements, and to the best of my knowledge and belief, it is true, correct, and complete. I further declare under penalties of perjury that if the facts upon which this form are based change, I will promptly notify the withholding agent.
Type or print payee’s name and title ___________________________________________________ Telephone _________________ Payee Information
□ Individuals — Certification of Residency:
I am a resident of California and I reside at the address shown above. If I become a nonresident at any time, I will promptly notify the withholding agent. See instructions for General Information D, Definitions.
Payee’s signature ▶ Date ______________________
□ Corporations:
The corporation has a permanent place of business in California at the address shown above or is qualified through the California Secretary of State (SOS) to do business in California. The corporation will file a California tax return. If this corporation ceases to have a permanent place of business in California or ceases to do any of the above, I will promptly notify the withholding agent. See instructions for General Information D, Definitions. □ Partnerships or Limited Liability Companies (LLCs):
The partnership or LLC has a permanent place of business in California at the address shown above or is registered with the California SOS, and is subject to the laws of California. The partnership or LLC will file a California tax return. If the partnership or LLC ceases to do any of the above, I will promptly inform the withholding agent. For withholding purposes, a limited liability partnership (LLP) is treated like any other partnership. □ Insurance Companies, Individual Retirement Arrangements (IRAs), or Qualified Pension/Profit-Sharing Plans:
The entity is an insurance company, IRA, or a federally qualified pension or profit-sharing plan. □ California Trusts:
At least one trustee and one noncontingent beneficiary of the above-named trust is a California resident. The trust will file a California fiduciary tax return. If the trustee or noncontingent beneficiary becomes a nonresident at any time, I will promptly notify the withholding agent.
□ Estates — Certification of Residency of Deceased Person:
I am the executor of the above-named person’s estate or trust. The decedent was a California resident at the time of death.
The estate will file a California fiduciary tax return.
□ Nonmilitary Spouse of a Military Servicemember:
I am a nonmilitary spouse of a military servicemember and I meet the Military Spouse Residency Relief Act (MSRRA) requirements. See instructions for General Information E, MSRRA. □ Tax-Exempt Entities:
The entity is exempt from tax under California Revenue and Taxation Code (R&TC) Section 23701 ______ Internal Revenue Code Section 501(c) _____
the withholding agent. Individuals cannot be tax-exempt entities. (insert letter) or
(insert number). If this entity ceases to be exempt from tax, I will promptly notify
EXHIBIT B
DATE (MM/DD/YYYY) CERTIFICATE OF LIABILITY INSURANCE
PRODUCER CONTACT NAME: PHONE FAX
(A/C, No, Ext): (A/C, No): EMAIL ADDRESS:
INSURER(S) AFFORDING COVERAGE NAIC #
INSURER A :
INSURED INSURER B :
INSURER C :
INSURER D :
INSURER E :
INSURER F :
COVERAGES CERTIFICATE NUMBER: REVISION NUMBER:
INSR
LTR TYPE OF INSURANCE ADDLINSR
SUBR WVD POLICY NUMBER POLICY EFF
(MM/DD/YYYY)
POLICY EXP
(MM/DD/YYYY) LIMITS
AUTHORIZED REPRESENTATIVE
CLAIMS-MADE OCCUR
GEN'L AGGREGATE LIMIT APPLIES PER:
POLICY PROJECT LOC
OTHER:
AUTOMOBILE LIABILITY
ANY AUTO
OWNED
AUTOS ONLY
SCHEDULED
AUTOS HIRED
AUTOS ONLY
NON-OWNED
AUTOS ONLY
UMBRELLA LIAB
EXCESS LIAB
OCCUR
CLAIMS-MADE DED RETENTION $
WORKERS COMPENSATION
AND EMPLOYERS' LIABILITY
ANY PROPRIETOR/PARTNER/EXECUTIVE
OFFICER/MEMBER EXCLUDED?
(Mandatory in NH)
If yes, describe under
DESCRIPTION OF OPERATIONS below
Y / N
N / A
EACH OCCURRENCE
DAMAGE TO RENTED
PREMISES (Ea occurrence)
MED EXP (Any one person)
PERSONAL & ADV INJURY
GENERAL AGGREGATE
PRODUCTS - COMP/OP AGG
COMBINED SINGLE LIMIT
(Ea accident)
BODILY INJURY (Per person)
BODILY INJURY (Per accident)
PROPERTY DAMAGE
(Per accident)
EACH OCCURRENCE
AGGREGATE
PER
STATUTE
OTH- ER
E.L. EACH ACCIDENT
E.L. DISEASE - EA EMPLOYEE
E.L. DISEASE - POLICY LIMIT
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required)
CERTIFICATE HOLDER CANCELLATION
ACORD 25 (2016/03) © 1988-2015 ACORD CORPORATION. All rights reserved.
The ACORD name and logo are registered marks of ACORD
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).
The Swenson Group Inc
1410 Stealth St
Livermore, CA 94551-9358
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.
Refer to attached
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS.
06/03/2024
Sentry Customer Service
800-473-6879 800-514-7191
[email protected]
Sentry Insurance Company 24988
1085771
A
X
X
X
2531405003 06/11/2023 06/11/2024
5,000,000
5,000,000
PRODUCTS - COMP/OP AGG 5,000,000
Sentry Insurance
1800 North Point Drive
Stevens Point, WI 54481
BUSINESSOWNERS LIABILITY
X
A
X
X
X X 2531405001 06/11/2023 06/11/2024
2,000,000
300,000
10,000
2,000,000
6,000,000
6,000,000
A X
X
X X 2531405002 06/11/2023 06/11/2024
1,000,000
City of South San Francisco
400 Grand Ave
PO Box 711
South San Francisco, CA 94083-0711
06/03/2024 2531405
Sentry Insurance Company
1 00001 0000000000 24155 0 N 6b07bf4a-6b43-4630-9bbc-ea4f5295546f AGENCY CUSTOMER ID:
LOC #:
ADDITIONAL REMARKS SCHEDULE Page of
AGENCY
POLICY NUMBER
CARRIER NAIC CODE
ADDITIONAL REMARKS
NAMED INSURED
EFFECTIVE DATE:
The Swenson Group Inc
XXXXXX5532
2 2
James Simonson
2531405001
Sentry Insurance Company 24988 06/11/2023
THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, FORM NUMBER: ACORD 25 FORM TITLE: Certificate of Liability Insurance Businessowners
GL Coverage provided is primary and non-contributory per the terms of endorsement BP 14 88. Commercial Excess Umbrella liability coverage follows form with the underlying insurance coverage subject to policy terms and conditions. Policy includes 30-day notice of cancellation.
ACORD 101 (2008/01) © 2008 ACORD CORPORATION. All rights reserved.
The ACORD name and logo are registered marks of ACORD 06/03/2024 2531405 Sentry Insurance Company
BP 04 50 07 13 Page 1 of 2
Change effective 05/31/2024
06/03/2024 2531405
Sentry Insurance Company
POLICY NUMBER:
SCHEDULE
Information required to complete this Schedule, if not shown above, will be shown in the Declarations.
Person(s) Or Organization(s) Location(s) Of Covered Operations Name Of Additional Insured
BUSINESSOWNERS
BP 04 50 07 13
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
ADDITIONAL INSURED - OWNERS, LESSEES
OR CONTRACTORS - SCHEDULED PERSON
OR ORGANIZATION
Section II - Liability is amended as follows:
A. The following is added to Paragraph C. Who Is An
Insured:
3. Any person(s) or organization(s) shown in the
Schedule is also an additional insured, but
only with respect to liability for "bodily injury",
"property damage" or "personal and
advertising injury" caused, in whole or in part,
by:
a. Your acts or omissions; or
b. The acts or omissions of those acting on
your behalf;
in the performance of your ongoing operations
for the additional insured(s) at the location(s)
designated above.
However:
a. The insurance afforded to such additional
insured only applies to the extent permitted
by law; and
b. If coverage provided to the additional
insured is required by a contract or
agreement, the insurance afforded to such
additional insured will not be broader than
that which you are required by the contract
or agreement to provide for such additional
insured.
B. With respect to the insurance afforded to these
additional insureds, the following additional
exclusions apply:
This insurance does not apply to "bodily injury" or
"property damage" occurring after:
1. All work, including materials, parts or
equipment furnished in connection with such
work, on the project (other than service,
maintenance or repairs) to be performed by or
on behalf of the additional insured(s) at the
location of the covered operations has been
completed; or
2. That portion of "your work" out of which the
injury or damage arises has been put to its
intended use by any person or organization
other than another contractor or subcontractor
engaged in performing operations for a
principal as a part of the same project.
This endorsement modifies insurance provided under the following:
BUSINESSOWNERS COVERAGE FORM
© Insurance Services Office, Inc., 2012
City of South San Francisco
IT Dept
400 Grand Ave South San Francisco CA 94080
Description:
Onsite Delivery
2531405001
1 00001 0000000000 24155 0 N ed06f9e1-bf17-49ba-a68d-797255b9ee51 C. With respect to the insurance afforded to these
additional insureds, the following is added to
Paragraph D. Liability And Medical Expenses
Limits Of Insurance:
If coverage provided to the additional insured is
required by a contract or agreement, the most we
will pay on behalf of the additional insured is the
amount of insurance:
1. Required by the contract or agreement; or
2. Available under the applicable Limits Of
Insurance shown in the Declarations;
whichever is less.
This endorsement shall not increase the
applicable Limits Of Insurance shown in the
Declarations.
Change effective 05/31/2024
06/03/2024 2531405
Sentry Insurance Company
BP 04 50 07 13 Page 1 of 2
Change effective 05/31/2024
06/03/2024 2531405
Sentry Insurance Company
POLICY NUMBER:
SCHEDULE
Information required to complete this Schedule, if not shown above, will be shown in the Declarations.
Person(s) Or Organization(s) Location(s) Of Covered Operations Name Of Additional Insured
BUSINESSOWNERS
BP 04 50 07 13
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
ADDITIONAL INSURED - OWNERS, LESSEES
OR CONTRACTORS - SCHEDULED PERSON
OR ORGANIZATION
Section II - Liability is amended as follows:
A. The following is added to Paragraph C. Who Is An
Insured:
3. Any person(s) or organization(s) shown in the
Schedule is also an additional insured, but
only with respect to liability for "bodily injury",
"property damage" or "personal and
advertising injury" caused, in whole or in part,
by:
a. Your acts or omissions; or
b. The acts or omissions of those acting on
your behalf;
in the performance of your ongoing operations
for the additional insured(s) at the location(s)
designated above.
However:
a. The insurance afforded to such additional
insured only applies to the extent permitted
by law; and
b. If coverage provided to the additional
insured is required by a contract or
agreement, the insurance afforded to such
additional insured will not be broader than
that which you are required by the contract
or agreement to provide for such additional
insured.
B. With respect to the insurance afforded to these
additional insureds, the following additional
exclusions apply:
This insurance does not apply to "bodily injury" or
"property damage" occurring after:
1. All work, including materials, parts or
equipment furnished in connection with such
work, on the project (other than service,
maintenance or repairs) to be performed by or
on behalf of the additional insured(s) at the
location of the covered operations has been
completed; or
2. That portion of "your work" out of which the
injury or damage arises has been put to its
intended use by any person or organization
other than another contractor or subcontractor
engaged in performing operations for a
principal as a part of the same project.
This endorsement modifies insurance provided under the following:
BUSINESSOWNERS COVERAGE FORM
© Insurance Services Office, Inc., 2012
City of South San Francisco 400 Grand Ave South San Francisco CA 94080 Description:
Onsite for Work
2531405001
1 00001 0000000000 24155 0 N 6c316cec-fa09-4405-b369-177dfeca14a1 C. With respect to the insurance afforded to these
additional insureds, the following is added to
Paragraph D. Liability And Medical Expenses
Limits Of Insurance:
If coverage provided to the additional insured is
required by a contract or agreement, the most we
will pay on behalf of the additional insured is the
amount of insurance:
1. Required by the contract or agreement; or
2. Available under the applicable Limits Of
Insurance shown in the Declarations;
whichever is less.
This endorsement shall not increase the
applicable Limits Of Insurance shown in the
Declarations.
Change effective 05/31/2024
06/03/2024 2531405
Sentry Insurance Company
2531405001
City of South San Francisco
SCHEDULE
Information required to complete this Schedule, if not shown above, will be shown in the Declarations.
Name Of Person Or Organization:
POLICY NUMBER: BUSINESSOWNERS
BP 04 97 01 06
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
WAIVER OF TRANSFER OF RIGHTS OF RECOVERY
AGAINST OTHERS TO US
This endorsement modifies insurance provided under the following:
BUSINESSOWNERS COVERAGE FORM
Paragraph K. Transfer Of Rights Of Recovery
Against Others To Us in Section III - Common
Policy Conditions is amended by the addition of the
following:
We waive any right of recovery we may have against
the person or organization shown in the Schedule
above because of payments we make for injury or
damage arising out of your ongoing operations or
"your work" done under a contract with that person
or organization and included in the
"products-completed operations hazard". This waiver
applies only to the person or organization shown in
the Schedule above.
© ISO Properties, Inc., 2004
2531405
Sentry Insurance Company 06/03/2024
Change effective 05/31/2024
BP 04 97 01 06 Page 1 of 1
bf522663-0b41-4fa7-9248-8860f82c5f64
POLICY NUMBER:
IL 70 60 08 15
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
NOTICE OF CANCELLATION TO OTHERS
This endorsement modifies the coverage provided under the following:
COMMERCIAL AUTO COVERAGE PART
COMMERCIAL EXCESS/UMBRELLA COVERAGE PART
COMMERCIAL GENERAL LIABILITY COVERAGE PART
COMMERCIAL INLAND MARINE COVERAGE PART
With respect to the coverage provided by this endorsement, the provisions of the Coverage Form apply unless modified by the endorsement.
SCHEDULE
Name Of Person(s)
Or Organization(s) Number of Days Notice
30 Information required to complete this Schedule, if not shown above, will be shown in the Declarations.
The following additional condition is added:
A. Notice of Cancellation to Others
1. If we send notice of cancellation to the Named
Insured shown in the declarations, for a reason
other than nonpayment of premium, we will
provide notice of such cancellation to the
person(s) or organization(s) listed in the
schedule of this endorsement (the schedule);
2. This notice:
a. Will be provided not less than the number
of days shown in the schedule prior to the
cancellation effective date indicated in the
schedule;
b. If mailed, will be sent to the mailing address
known to us at that time, with proof of
mailing constituting sufficient proof of
notice; and
c. Will not extend the cancellation effective
date nor impact or negate any cancellation
of the policy;
3. We are not obligated to notify the person(s) or
organization(s) shown in the schedule of the
expiration, renewal on different terms or
nonrenewal of the policy to which this
endorsement is attached; and
4. The provisions of this endorsement do not
entitle the person(s) or organization(s) listed in
the schedule to any benefits, rights nor
protections not already provided for under the
policy.
All other terms and conditions of the policy remain
unchanged.
City of South San Francisco
2531405002
Change effective 05/31/2024
IL 70 60 08 15 Page 1 of 1
06/03/2024 2531405
Sentry Insurance Company
1 00001 0000000000 24155 0 N 6070d56f-298b-48e6-9efc-016677c9753f POLICY NUMBER:
SCHEDULE
COMMERCIAL AUTO
CA 76 01 06 15
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
DESIGNATED INSURED - PRIMARY AND
NONCONTRIBUTORY - COVERED AUTOS
LIABILITY COVERAGE
This endorsement modifies insurance provided under the following:
BUSINESS AUTO COVERAGE FORM
MOTOR CARRIER COVERAGE FORM
AUTO DEALERS COVERAGE FORM
With respect to coverage 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" for Covered Autos Liability Coverage under the Who Is An Insured provision of the Coverage Form.
This endorsement changes the policy effective on the inception date of the policy unless another date is indicated.
Named Insured: The Swenson Group Inc
Endorsement Effective Date: 05/31/2024
Name Of Person(s) Or Organization(s):
City of South San Francisco
Information required to complete this Schedule, if not shown above, will be shown in the Declarations.
A. Each person or organization shown in the
Schedule is an "insured" for Covered Autos
Liability Coverage, but only to the extent that
person or organization qualifies as an "insured"
under the Who Is An Insured provision contained
in:
(1) Paragraph A.1. of Section II - Covered Autos
Liability Coverage in the Business Auto and
Motor Carrier Coverage Forms; or
(2) Paragraph D.2. of Section I - Covered Autos
Coverages of the Auto Dealers Coverage
Form.
B. Primary And Noncontributory Insurance
This insurance is primary to and will not seek
contribution from any other auto insurance issued
to the person or organization in the schedule
under your policy provided that:
(1) The person or organization is a Named Insured
under such other insurance; and
(2) Prior to the “accident” you have agreed in
writing in a contract or agreement that this
insurance would be primary and would not
seek contribution from any other insurance
available to the person or organization.
Includes copyrighted material of Insurance Services Office, Inc., with its permission.
2531405002
Change effective 05/31/2024
CA 76 01 06 15 Page 1 of 1
06/03/2024 2531405
Sentry Insurance Company
1 00001 0000000000 24155 0 N 057f4d03-2dc4-467a-adea-ee98e8883aee Named Insured:
Endorsement Effective Date:
Name(s) Of Person(s) Or Organization(s):
POLICY NUMBER: 2531405002 COMMERCIAL AUTO
CA 04 44 10 13
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
WAIVER OF TRANSFER OF RIGHTS OF RECOVERY
AGAINST OTHERS TO US (WAIVER OF SUBROGATION)
This endorsement modifies insurance provided under the following:
AUTO DEALERS COVERAGE FORM
BUSINESS AUTO COVERAGE FORM
MOTOR CARRIER COVERAGE FORM
With respect to coverage provided by this endorsement, the provisions of the Coverage Form apply unless modified by the endorsement.
This endorsement changes the policy effective on the inception date of the policy unless another date is indicated below.
SCHEDULE
City of South San Francisco
Information required to complete this Schedule, if not shown above, will be shown in the Declarations.
The Transfer Of Rights Of Recovery Against
Others To Us condition does not apply to the
person(s) or organization(s) shown in the Schedule,
but only to the extent that subrogation is waived
prior to the "accident" or the "loss" under a contract
with that person or organization.
© Insurance Services Office, Inc., 2011
The Swenson Group Inc
05/31/2024
Change effective 05/31/2024
CA 04 44 10 13 Page 1 of 1
06/03/2024 2531405
Sentry Insurance Company
1 00001 0000000000 24155 0 N 2b3d5cd3-0935-4908-a231-98b736f3fc09 IL 70 58 02 14
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
NOTICE OF CANCELLATION - CERTIFICATE HOLDERS
This endorsement modifies insurance provided under the following:
BUSINESSOWNERS COVERAGE FORM
COMMERCIAL AUTOMOBILE COVERAGE PARTS
COMMERCIAL PROPERTY COVERAGE PART
CRIME AND FIDELITY COVERAGE PART
COMMERCIAL INLAND MARINE COVERAGE PART
COMMERCIAL GENERAL LIABILITY COVERAGE PARTS
COMMERCIAL EXCESS/UMBRELLA LIABILITY COVERAGE FORM
EMPLOYMENT RELATED PRACTICES LIABILITY
POLLUTION LIABILITY COVERAGE
ERRORS AND OMISSIONS COVERAGE FORM
In the event we cancel this policy, we shall endeavor to also mail to the person(s) or organization(s) listed in the Schedule for this endorsement advance written notice of cancellation.
This notification of cancellation of the policy is intended as a courtesy only. Our failure to provide such notification to the person(s) or organization(s) shown in the Schedule will not extend any policy cancellation date nor impact or negate any cancellation of the policy. This endorsement does not entitle the person(s) or organization(s) listed or described in the Schedule below to any benefit, rights or protection under this policy.
Failure by us to provide this notice of cancellation to the person(s) or organization(s) listed or described in the Schedule below will not impose liability of any kind upon us.
Any of these provisions that conflict with a law that controls the notice of cancellation of the insurance in this endorsement is changed by this statement to comply with the law.
Schedule
Person(s) or Organization(s) including mailing address:
City of South San Francisco
400 Grand Ave
PO Box 711
South San Francisco, CA 94083-0711
All other terms and conditions of this policy remain unchanged.
Change effective 05/31/2024
IL 70 58 02 14 Page 1 of 1
06/03/2024 2531405
Sentry Insurance Company
1 00001 0000000000 24155 0 N 34216540-9652-42a0-a4b1-b4e08144c33b IL 70 58 02 14
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
NOTICE OF CANCELLATION - CERTIFICATE HOLDERS
This endorsement modifies insurance provided under the following:
BUSINESSOWNERS COVERAGE FORM
COMMERCIAL AUTOMOBILE COVERAGE PARTS
COMMERCIAL PROPERTY COVERAGE PART
CRIME AND FIDELITY COVERAGE PART
COMMERCIAL INLAND MARINE COVERAGE PART
COMMERCIAL GENERAL LIABILITY COVERAGE PARTS
COMMERCIAL EXCESS/UMBRELLA LIABILITY COVERAGE FORM
EMPLOYMENT RELATED PRACTICES LIABILITY
POLLUTION LIABILITY COVERAGE
ERRORS AND OMISSIONS COVERAGE FORM
In the event we cancel this policy, we shall endeavor to also mail to the person(s) or organization(s) listed in the Schedule for this endorsement advance written notice of cancellation.
This notification of cancellation of the policy is intended as a courtesy only. Our failure to provide such notification to the person(s) or organization(s) shown in the Schedule will not extend any policy cancellation date nor impact or negate any cancellation of the policy. This endorsement does not entitle the person(s) or organization(s) listed or described in the Schedule below to any benefit, rights or protection under this policy.
Failure by us to provide this notice of cancellation to the person(s) or organization(s) listed or described in the Schedule below will not impose liability of any kind upon us.
Any of these provisions that conflict with a law that controls the notice of cancellation of the insurance in this endorsement is changed by this statement to comply with the law.
Schedule
Person(s) or Organization(s) including mailing address:
City of South San Francisco
IT Dept
400 Grand Ave
PO Box 711
South San Francisco, CA 94083-0711
All other terms and conditions of this policy remain unchanged.
Change effective 05/31/2024
IL 70 58 02 14 Page 1 of 1
06/03/2024 2531405
Sentry Insurance Company
1 00001 0000000000 24155 0 N d9002e44-ce3b-4873-a0f3-e5c38f56430e
DATE (MM/DD/YYYY) CERTIFICATE OF LIABILITY INSURANCE
PRODUCER CONTACT NAME: PHONE FAX
(A/C, No, Ext): (A/C, No): EMAIL ADDRESS:
INSURER(S) AFFORDING COVERAGE NAIC #
INSURER A :
INSURED INSURER B :
INSURER C :
INSURER D :
INSURER E :
INSURER F :
COVERAGES CERTIFICATE NUMBER: REVISION NUMBER:
INSR
LTR TYPE OF INSURANCE ADDLINSR
SUBR WVD POLICY NUMBER POLICY EFF
(MM/DD/YYYY)
POLICY EXP
(MM/DD/YYYY) LIMITS
AUTHORIZED REPRESENTATIVE
CLAIMS-MADE OCCUR
GEN'L AGGREGATE LIMIT APPLIES PER:
POLICY PROJECT LOC
OTHER:
AUTOMOBILE LIABILITY
ANY AUTO
OWNED
AUTOS ONLY
SCHEDULED
AUTOS HIRED
AUTOS ONLY
NON-OWNED
AUTOS ONLY
UMBRELLA LIAB
EXCESS LIAB
OCCUR
CLAIMS-MADE DED RETENTION $
WORKERS COMPENSATION
AND EMPLOYERS' LIABILITY
ANY PROPRIETOR/PARTNER/EXECUTIVE
OFFICER/MEMBER EXCLUDED?
(Mandatory in NH)
If yes, describe under
DESCRIPTION OF OPERATIONS below
Y / N
N / A
EACH OCCURRENCE
DAMAGE TO RENTED
PREMISES (Ea occurrence)
MED EXP (Any one person)
PERSONAL & ADV INJURY
GENERAL AGGREGATE
PRODUCTS - COMP/OP AGG
COMBINED SINGLE LIMIT
(Ea accident)
BODILY INJURY (Per person)
BODILY INJURY (Per accident)
PROPERTY DAMAGE
(Per accident)
EACH OCCURRENCE
AGGREGATE
PER
STATUTE
OTH- ER
E.L. EACH ACCIDENT
E.L. DISEASE - EA EMPLOYEE
E.L. DISEASE - POLICY LIMIT
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required)
CERTIFICATE HOLDER CANCELLATION
ACORD 25 (2016/03) © 1988-2015 ACORD CORPORATION. All rights reserved.
The ACORD name and logo are registered marks of ACORD
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).
The Swenson Group Inc
1410 Stealth St
Livermore, CA 94551-9358
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.
Refer to attached
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS.
06/03/2024
Sentry Customer Service
800-473-6879 800-514-7191
[email protected]
Sentry Insurance Company 24988
1085771
A
X
X
X
2531405003 06/11/2024 06/11/2025
5,000,000
5,000,000
PRODUCTS - COMP/OP AGG 5,000,000
Sentry Insurance
1800 North Point Drive
Stevens Point, WI 54481
BUSINESSOWNERS LIABILITY
X
A
X
X
X X 2531405001 06/11/2024 06/11/2025
2,000,000
300,000
10,000
2,000,000
6,000,000
6,000,000
A X
X
X X 2531405002 06/11/2024 06/11/2025
1,000,000
City of South San Francisco
400 Grand Ave
PO Box 711
South San Francisco, CA 94083-0711
06/03/2024 2531405
Sentry Insurance Company
1 00001 0000000000 24155 0 N 7518401c-0613-429a-8370-997f27ec6ff2 0027020044375659695094083071111 AGENCY CUSTOMER ID:
LOC #:
ADDITIONAL REMARKS SCHEDULE Page of
AGENCY
POLICY NUMBER
CARRIER NAIC CODE
ADDITIONAL REMARKS
NAMED INSURED
EFFECTIVE DATE:
The Swenson Group Inc
XXXXXX5532
2 2
James Simonson
2531405001
Sentry Insurance Company 24988 06/11/2024
THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, FORM NUMBER: ACORD 25 FORM TITLE: Certificate of Liability Insurance Businessowners
GL Coverage provided is primary and non-contributory per the terms of endorsement BP 14 88. Commercial Excess Umbrella liability coverage follows form with the underlying insurance coverage subject to policy terms and conditions. Policy includes 30-day notice of cancellation.
ACORD 101 (2008/01) © 2008 ACORD CORPORATION. All rights reserved.
The ACORD name and logo are registered marks of ACORD 06/03/2024 2531405 Sentry Insurance Company
BP 04 50 07 13 Page 1 of 2
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Sentry Insurance Company
POLICY NUMBER:
SCHEDULE
Information required to complete this Schedule, if not shown above, will be shown in the Declarations.
Person(s) Or Organization(s) Location(s) Of Covered Operations Name Of Additional Insured
BUSINESSOWNERS
BP 04 50 07 13
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
ADDITIONAL INSURED - OWNERS, LESSEES
OR CONTRACTORS - SCHEDULED PERSON
OR ORGANIZATION
Section II - Liability is amended as follows:
A. The following is added to Paragraph C. Who Is An
Insured:
3. Any person(s) or organization(s) shown in the
Schedule is also an additional insured, but
only with respect to liability for "bodily injury",
"property damage" or "personal and
advertising injury" caused, in whole or in part,
by:
a. Your acts or omissions; or
b. The acts or omissions of those acting on
your behalf;
in the performance of your ongoing operations
for the additional insured(s) at the location(s)
designated above.
However:
a. The insurance afforded to such additional
insured only applies to the extent permitted
by law; and
b. If coverage provided to the additional
insured is required by a contract or
agreement, the insurance afforded to such
additional insured will not be broader than
that which you are required by the contract
or agreement to provide for such additional
insured.
B. With respect to the insurance afforded to these
additional insureds, the following additional
exclusions apply:
This insurance does not apply to "bodily injury" or
"property damage" occurring after:
1. All work, including materials, parts or
equipment furnished in connection with such
work, on the project (other than service,
maintenance or repairs) to be performed by or
on behalf of the additional insured(s) at the
location of the covered operations has been
completed; or
2. That portion of "your work" out of which the
injury or damage arises has been put to its
intended use by any person or organization
other than another contractor or subcontractor
engaged in performing operations for a
principal as a part of the same project.
This endorsement modifies insurance provided under the following:
BUSINESSOWNERS COVERAGE FORM
© Insurance Services Office, Inc., 2012
City of South San Francisco 400 Grand Ave South San Francisco CA 94080 Description:
Onsite for Work
2531405001
1 00001 0000000000 24155 0 N e01b193e-24db-417d-8418-f9732c583b57 0027020044375659695694083071111 C. With respect to the insurance afforded to these
additional insureds, the following is added to
Paragraph D. Liability And Medical Expenses
Limits Of Insurance:
If coverage provided to the additional insured is
required by a contract or agreement, the most we
will pay on behalf of the additional insured is the
amount of insurance:
1. Required by the contract or agreement; or
2. Available under the applicable Limits Of
Insurance shown in the Declarations;
whichever is less.
This endorsement shall not increase the
applicable Limits Of Insurance shown in the
Declarations.
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Sentry Insurance Company
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Sentry Insurance Company
POLICY NUMBER:
SCHEDULE
Information required to complete this Schedule, if not shown above, will be shown in the Declarations.
Person(s) Or Organization(s) Location(s) Of Covered Operations Name Of Additional Insured
BUSINESSOWNERS
BP 04 50 07 13
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
ADDITIONAL INSURED - OWNERS, LESSEES
OR CONTRACTORS - SCHEDULED PERSON
OR ORGANIZATION
Section II - Liability is amended as follows:
A. The following is added to Paragraph C. Who Is An
Insured:
3. Any person(s) or organization(s) shown in the
Schedule is also an additional insured, but
only with respect to liability for "bodily injury",
"property damage" or "personal and
advertising injury" caused, in whole or in part,
by:
a. Your acts or omissions; or
b. The acts or omissions of those acting on
your behalf;
in the performance of your ongoing operations
for the additional insured(s) at the location(s)
designated above.
However:
a. The insurance afforded to such additional
insured only applies to the extent permitted
by law; and
b. If coverage provided to the additional
insured is required by a contract or
agreement, the insurance afforded to such
additional insured will not be broader than
that which you are required by the contract
or agreement to provide for such additional
insured.
B. With respect to the insurance afforded to these
additional insureds, the following additional
exclusions apply:
This insurance does not apply to "bodily injury" or
"property damage" occurring after:
1. All work, including materials, parts or
equipment furnished in connection with such
work, on the project (other than service,
maintenance or repairs) to be performed by or
on behalf of the additional insured(s) at the
location of the covered operations has been
completed; or
2. That portion of "your work" out of which the
injury or damage arises has been put to its
intended use by any person or organization
other than another contractor or subcontractor
engaged in performing operations for a
principal as a part of the same project.
This endorsement modifies insurance provided under the following:
BUSINESSOWNERS COVERAGE FORM
© Insurance Services Office, Inc., 2012
City of South San Francisco
IT Dept
400 Grand Ave South San Francisco CA 94080
Description:
Onsite Delivery
2531405001
1 00001 0000000000 24155 0 N be2b23d0-a5c8-445f-aa3b-2a3ba84f1ce2 0027020044375659698594083071111 C. With respect to the insurance afforded to these
additional insureds, the following is added to
Paragraph D. Liability And Medical Expenses
Limits Of Insurance:
If coverage provided to the additional insured is
required by a contract or agreement, the most we
will pay on behalf of the additional insured is the
amount of insurance:
1. Required by the contract or agreement; or
2. Available under the applicable Limits Of
Insurance shown in the Declarations;
whichever is less.
This endorsement shall not increase the
applicable Limits Of Insurance shown in the
Declarations.
Change effective 06/11/2024
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Sentry Insurance Company
2531405001
City of South San Francisco
SCHEDULE
Information required to complete this Schedule, if not shown above, will be shown in the Declarations.
Name Of Person Or Organization:
POLICY NUMBER: BUSINESSOWNERS
BP 04 97 01 06
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
WAIVER OF TRANSFER OF RIGHTS OF RECOVERY
AGAINST OTHERS TO US
This endorsement modifies insurance provided under the following:
BUSINESSOWNERS COVERAGE FORM
Paragraph K. Transfer Of Rights Of Recovery
Against Others To Us in Section III - Common
Policy Conditions is amended by the addition of the
following:
We waive any right of recovery we may have against
the person or organization shown in the Schedule
above because of payments we make for injury or
damage arising out of your ongoing operations or
"your work" done under a contract with that person
or organization and included in the
"products-completed operations hazard". This waiver
applies only to the person or organization shown in
the Schedule above.
© ISO Properties, Inc., 2004
2531405
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0027020044375659695594083071111
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BP 04 97 01 06 Page 1 of 1
dc8042a1-4e7f-4453-b638-1c38b5aeef27
POLICY NUMBER:
IL 70 60 08 15
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
NOTICE OF CANCELLATION TO OTHERS
This endorsement modifies the coverage provided under the following:
COMMERCIAL AUTO COVERAGE PART
COMMERCIAL EXCESS/UMBRELLA COVERAGE PART
COMMERCIAL GENERAL LIABILITY COVERAGE PART
COMMERCIAL INLAND MARINE COVERAGE PART
With respect to the coverage provided by this endorsement, the provisions of the Coverage Form apply unless modified by the endorsement.
SCHEDULE
Name Of Person(s)
Or Organization(s) Number of Days Notice
30 Information required to complete this Schedule, if not shown above, will be shown in the Declarations.
The following additional condition is added:
A. Notice of Cancellation to Others
1. If we send notice of cancellation to the Named
Insured shown in the declarations, for a reason
other than nonpayment of premium, we will
provide notice of such cancellation to the
person(s) or organization(s) listed in the
schedule of this endorsement (the schedule);
2. This notice:
a. Will be provided not less than the number
of days shown in the schedule prior to the
cancellation effective date indicated in the
schedule;
b. If mailed, will be sent to the mailing address
known to us at that time, with proof of
mailing constituting sufficient proof of
notice; and
c. Will not extend the cancellation effective
date nor impact or negate any cancellation
of the policy;
3. We are not obligated to notify the person(s) or
organization(s) shown in the schedule of the
expiration, renewal on different terms or
nonrenewal of the policy to which this
endorsement is attached; and
4. The provisions of this endorsement do not
entitle the person(s) or organization(s) listed in
the schedule to any benefits, rights nor
protections not already provided for under the
policy.
All other terms and conditions of the policy remain
unchanged.
City of South San Francisco
2531405002
Change effective 06/11/2024
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1 00001 0000000000 24155 0 N cdb14a96-2729-4eb7-953e-ea08896844c4 0027020044375659696794083071111 POLICY NUMBER:
SCHEDULE
COMMERCIAL AUTO
CA 76 01 06 15
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
DESIGNATED INSURED - PRIMARY AND
NONCONTRIBUTORY - COVERED AUTOS
LIABILITY COVERAGE
This endorsement modifies insurance provided under the following:
BUSINESS AUTO COVERAGE FORM
MOTOR CARRIER COVERAGE FORM
AUTO DEALERS COVERAGE FORM
With respect to coverage 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" for Covered Autos Liability Coverage under the Who Is An Insured provision of the Coverage Form.
This endorsement changes the policy effective on the inception date of the policy unless another date is indicated.
Named Insured: The Swenson Group Inc
Endorsement Effective Date: 06/11/2024
Name Of Person(s) Or Organization(s):
City of South San Francisco
Information required to complete this Schedule, if not shown above, will be shown in the Declarations.
A. Each person or organization shown in the
Schedule is an "insured" for Covered Autos
Liability Coverage, but only to the extent that
person or organization qualifies as an "insured"
under the Who Is An Insured provision contained
in:
(1) Paragraph A.1. of Section II - Covered Autos
Liability Coverage in the Business Auto and
Motor Carrier Coverage Forms; or
(2) Paragraph D.2. of Section I - Covered Autos
Coverages of the Auto Dealers Coverage
Form.
B. Primary And Noncontributory Insurance
This insurance is primary to and will not seek
contribution from any other auto insurance issued
to the person or organization in the schedule
under your policy provided that:
(1) The person or organization is a Named Insured
under such other insurance; and
(2) Prior to the “accident” you have agreed in
writing in a contract or agreement that this
insurance would be primary and would not
seek contribution from any other insurance
available to the person or organization.
Includes copyrighted material of Insurance Services Office, Inc., with its permission.
2531405002
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1 00001 0000000000 24155 0 N 3f2cf9a6-981d-41d5-a662-ae40d1282fef 0027020044375659696794083071111 Named Insured:
Endorsement Effective Date:
Name(s) Of Person(s) Or Organization(s):
POLICY NUMBER: 2531405002 COMMERCIAL AUTO
CA 04 44 10 13
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
WAIVER OF TRANSFER OF RIGHTS OF RECOVERY
AGAINST OTHERS TO US (WAIVER OF SUBROGATION)
This endorsement modifies insurance provided under the following:
AUTO DEALERS COVERAGE FORM
BUSINESS AUTO COVERAGE FORM
MOTOR CARRIER COVERAGE FORM
With respect to coverage provided by this endorsement, the provisions of the Coverage Form apply unless modified by the endorsement.
This endorsement changes the policy effective on the inception date of the policy unless another date is indicated below.
SCHEDULE
City of South San Francisco
Information required to complete this Schedule, if not shown above, will be shown in the Declarations.
The Transfer Of Rights Of Recovery Against
Others To Us condition does not apply to the
person(s) or organization(s) shown in the Schedule,
but only to the extent that subrogation is waived
prior to the "accident" or the "loss" under a contract
with that person or organization.
© Insurance Services Office, Inc., 2011
The Swenson Group Inc
06/11/2024
Change effective 06/11/2024
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1 00001 0000000000 24155 0 N 89b49909-3365-4dc3-9917-f900855460b6 0027020044375659696794083071111 IL 70 58 02 14
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
NOTICE OF CANCELLATION - CERTIFICATE HOLDERS
This endorsement modifies insurance provided under the following:
BUSINESSOWNERS COVERAGE FORM
COMMERCIAL AUTOMOBILE COVERAGE PARTS
COMMERCIAL PROPERTY COVERAGE PART
CRIME AND FIDELITY COVERAGE PART
COMMERCIAL INLAND MARINE COVERAGE PART
COMMERCIAL GENERAL LIABILITY COVERAGE PARTS
COMMERCIAL EXCESS/UMBRELLA LIABILITY COVERAGE FORM
EMPLOYMENT RELATED PRACTICES LIABILITY
POLLUTION LIABILITY COVERAGE
ERRORS AND OMISSIONS COVERAGE FORM
In the event we cancel this policy, we shall endeavor to also mail to the person(s) or organization(s) listed in the Schedule for this endorsement advance written notice of cancellation.
This notification of cancellation of the policy is intended as a courtesy only. Our failure to provide such notification to the person(s) or organization(s) shown in the Schedule will not extend any policy cancellation date nor impact or negate any cancellation of the policy. This endorsement does not entitle the person(s) or organization(s) listed or described in the Schedule below to any benefit, rights or protection under this policy.
Failure by us to provide this notice of cancellation to the person(s) or organization(s) listed or described in the Schedule below will not impose liability of any kind upon us.
Any of these provisions that conflict with a law that controls the notice of cancellation of the insurance in this endorsement is changed by this statement to comply with the law.
Schedule
Person(s) or Organization(s) including mailing address:
City of South San Francisco
400 Grand Ave
PO Box 711
South San Francisco, CA 94083-0711
All other terms and conditions of this policy remain unchanged.
Change effective 06/11/2024
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1 00001 0000000000 24155 0 N 42147644-b927-4c34-aef7-1920e0b4d4d1 0027020044375659695694083071111 IL 70 58 02 14
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
NOTICE OF CANCELLATION - CERTIFICATE HOLDERS
This endorsement modifies insurance provided under the following:
BUSINESSOWNERS COVERAGE FORM
COMMERCIAL AUTOMOBILE COVERAGE PARTS
COMMERCIAL PROPERTY COVERAGE PART
CRIME AND FIDELITY COVERAGE PART
COMMERCIAL INLAND MARINE COVERAGE PART
COMMERCIAL GENERAL LIABILITY COVERAGE PARTS
COMMERCIAL EXCESS/UMBRELLA LIABILITY COVERAGE FORM
EMPLOYMENT RELATED PRACTICES LIABILITY
POLLUTION LIABILITY COVERAGE
ERRORS AND OMISSIONS COVERAGE FORM
In the event we cancel this policy, we shall endeavor to also mail to the person(s) or organization(s) listed in the Schedule for this endorsement advance written notice of cancellation.
This notification of cancellation of the policy is intended as a courtesy only. Our failure to provide such notification to the person(s) or organization(s) shown in the Schedule will not extend any policy cancellation date nor impact or negate any cancellation of the policy. This endorsement does not entitle the person(s) or organization(s) listed or described in the Schedule below to any benefit, rights or protection under this policy.
Failure by us to provide this notice of cancellation to the person(s) or organization(s) listed or described in the Schedule below will not impose liability of any kind upon us.
Any of these provisions that conflict with a law that controls the notice of cancellation of the insurance in this endorsement is changed by this statement to comply with the law.
Schedule
Person(s) or Organization(s) including mailing address:
City of South San Francisco
IT Dept
400 Grand Ave
PO Box 711
South San Francisco, CA 94083-0711
All other terms and conditions of this policy remain unchanged.
Change effective 06/11/2024
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1 00001 0000000000 24155 0 N 1acc0a61-f586-4b7c-bf7f-22bbf75900ba 0027020044375659698594083071111 5/29/2024
Whitman & Samuelson Insurance Services, Inc.
CA Lic: 0273555
1012 Clegg Court
Petaluma CA 94954
Jessica Whitman
(707)794-8700 (888)415-6756
[email protected]
The Swenson Group, Inc
1410 Stealth St
Livermore CA 94551-9358
Hartford Casualty Insurance Company 29424
24-25 WC
A 57WECAP7HW9 1/28/2024 1/28/2025
X
1,000,000
1,000,000
1,000,000
This certificate is issued to provide evidence of coverage. Waiver of Subrogation applies, per written contract. 30 days notice applies.
City of South San Francisco
329 Miller Ave
South San Francisco, CA 94080
Scott Whitman/SUMMER
Y
The ACORD name and logo are registered marks of ACORD
CERTIFICATE HOLDER
© 1988-2014 ACORD CORPORATION. All rights reserved.
ACORD 25 (2014/01)
AUTHORIZED REPRESENTATIVE
CANCELLATION
DATE (MM/DD/YYYY) CERTIFICATE OF LIABILITY INSURANCE
JECT LOC PRO- POLICY
GEN'L AGGREGATE LIMIT APPLIES PER:
CLAIMS-MADE OCCUR
COMMERCIAL GENERAL LIABILITY
PREMISES (Ea occurrence) $
DAMAGE TO RENTED
EACH OCCURRENCE $
MED EXP (Any one person) $
PERSONAL & ADV INJURY $
GENERAL AGGREGATE $
PRODUCTS - COMP/OP AGG $
DED RETENTION $
CLAIMS-MADE
OCCUR
$
AGGREGATE $
EACH OCCURRENCE $
UMBRELLA LIAB
EXCESS LIAB
DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) INSR
LTR TYPE OF INSURANCE POLICY NUMBER
POLICY EFF
(MM/DD/YYYY)
POLICY EXP
(MM/DD/YYYY) LIMITS
PER
STATUTE
OTHER
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.
INSD
ADDL
WVD
SUBR
N / A
$
$
(Ea accident)
(Per accident)
OTHER:
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).
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.
INS025 (201401)
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
Countersigned by
Authorized Representative
Form WC 04 03 06 (1) Printed in U.S.A.
Process Date: 12/19/23 Policy Expiration Date: 01/28/25
WAIVER OF OUR RIGHT TO RECOVER FROM
OTHERS ENDORSEMENT - CALIFORNIA
Policy Number: 57 WEC AP7HW9 Endorsement Number:
Effective Date: 01/28/24 Effective hour is the same as stated on the Information Page of the policy.
Named Insured and Address: Swenson Group, Inc. (The)
1410 STEALTH ST
LIVERMORE CA 94551
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 whom you are required by written contract or agreement to obtain this waiver of rights from us
7061213 Form 590 2020
TAXABLE YEAR
2021 Withholding Exemption Certificate
CALIFORNIA FORM
590
The payee completes this form and submits it to the withholding agent. The withholding agent keeps this form with their records.
Withholding Agent Information
Name
Name □ SSN or ITIN □ FEIN □ CA Corp no. □ CA SOS file no.
Address (apt./ste., room, PO box, or PMB no.)
City (If you have a foreign address, see instructions.) State ZIP code Exemption Reason
Check only one box.
By checking the appropriate box below, the payee certifies the reason for the exemption from the California income tax withholding requirements on payment(s) made to the entity or individual.
CERTIFICATE OF PAYEE: Payee must complete and sign below.
To learn about your privacy rights, how we may use your information, and the consequences for not providing the requested information, go to ftb.ca.gov/forms and search for 1131. To request this notice by mail, call 800.852.5711.
Under penalties of perjury, I declare that I have examined the information on this form, including accompanying schedules and statements, and to the best of my knowledge and belief, it is true, correct, and complete. I further declare under penalties of perjury that if the facts upon which this form are based change, I will promptly notify the withholding agent.
Type or print payee’s name and title ___________________________________________________ Telephone _________________ Payee Information
□ Individuals — Certification of Residency:
I am a resident of California and I reside at the address shown above. If I become a nonresident at any time, I will promptly notify the withholding agent. See instructions for General Information D, Definitions.
Payee’s signature ▶ Date ______________________
□ Corporations:
The corporation has a permanent place of business in California at the address shown above or is qualified through the California Secretary of State (SOS) to do business in California. The corporation will file a California tax return. If this corporation ceases to have a permanent place of business in California or ceases to do any of the above, I will promptly notify the withholding agent. See instructions for General Information D, Definitions. □ Partnerships or Limited Liability Companies (LLCs):
The partnership or LLC has a permanent place of business in California at the address shown above or is registered with the California SOS, and is subject to the laws of California. The partnership or LLC will file a California tax return. If the partnership or LLC ceases to do any of the above, I will promptly inform the withholding agent. For withholding purposes, a limited liability partnership (LLP) is treated like any other partnership. □ Insurance Companies, Individual Retirement Arrangements (IRAs), or Qualified Pension/Profit-Sharing Plans:
The entity is an insurance company, IRA, or a federally qualified pension or profit-sharing plan. □ California Trusts:
At least one trustee and one noncontingent beneficiary of the above-named trust is a California resident. The trust will file a California fiduciary tax return. If the trustee or noncontingent beneficiary becomes a nonresident at any time, I will promptly notify the withholding agent.
□ Estates — Certification of Residency of Deceased Person:
I am the executor of the above-named person’s estate or trust. The decedent was a California resident at the time of death.
The estate will file a California fiduciary tax return.
□ Nonmilitary Spouse of a Military Servicemember:
I am a nonmilitary spouse of a military servicemember and I meet the Military Spouse Residency Relief Act (MSRRA) requirements. See instructions for General Information E, MSRRA. □ Tax-Exempt Entities:
The entity is exempt from tax under California Revenue and Taxation Code (R&TC) Section 23701 ______ Internal Revenue Code Section 501(c) _____
the withholding agent. Individuals cannot be tax-exempt entities. (insert letter) or
(insert number). If this entity ceases to be exempt from tax, I will promptly notify Exhibit B