INSR ADDL SUBR
LTR INSR WVD
DATE (MM/DD/YYYY)
PRODUCER CONTACT
NAME:
PHONE FAX
(A/C, No, Ext): (A/C, No):
E-MAIL
ADDRESS:
INSURER A :
INSURED INSURER B :
INSURER C :
INSURER D :
INSURER E :
INSURER F :
POLICY NUMBER
POLICY EFF POLICY EXP TYPE OF INSURANCE (MM/DD/YYYY) (MM/DD/YYYY) LIMITS
COMMERCIAL GENERAL LIABILITY
AUTOMOBILE LIABILITY
UMBRELLA LIAB
EXCESS LIAB
WORKERS COMPENSATION
AND EMPLOYERS' LIABILITY
DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required)
AUTHORIZED REPRESENTATIVE
INSURER(S) AFFORDING COVERAGE NAIC #
Y / N
N / A
(Mandatory in NH)
ANY PROPRIETOR/PARTNER/EXECUTIVE
OFFICER/MEMBER EXCLUDED?
EACH OCCURRENCE $
DAMAGE TO RENTED
CLAIMS-MADE OCCUR PREMISES (Ea occurrence) $
MED EXP (Any one person) $
PERSONAL & ADV INJURY $
GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $
PRODUCTS - COMP/OP AGG $
$
PROOTHER:
JECT LOC
COMBINED SINGLE LIMIT
(Ea accident) $
ANY AUTO BODILY INJURY (Per person) $
OWNED SCHEDULED BODILY INJURY (Per accident) $ AUTOS ONLY AUTOS
AUTOS ONLY
HIRED PROPERTY DAMAGE $
AUTOS ONLY (Per accident)
$
OCCUR EACH OCCURRENCE $
CLAIMS-MADE AGGREGATE $
DED RETENTION $ $
PER OTHSTATUTE ER
E.L. EACH ACCIDENT $
E.L. DISEASE - EA EMPLOYEE $
If yes, describe under
DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT $ POLICY
NON-OWNED
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 any 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) The ACORD name and logo are registered marks of ACORD
ACORDTM CERTIFICATE OF LIABILITY INSURANCE
Phoenix Insurance Company
Travelers Property Cas. Co. of America
Great American Alliance Insurance Co.
11/01/2024
USI Insurance Services, LLC
6100 Fairview Rd Ste 1400
Charlotte, NC 28210
704 543-0258
Susan McCormack
980-265-5819
[email protected]
Baker & Taylor, LLC
2810 Coliseum Center Drive
Charlotte, NC 28217
25623
25674
26832
A X
X
X X H630A0440117PHX24 11/02/2024 11/02/2025 1,000,000
1,000,000
10,000
1,000,000
2,000,000
2,000,000
B
X
X X
X X BAA051606124I3G 11/02/2024 11/02/2025 1,000,000
B X X
X 10,000
X X CUPA051781924I3 11/02/2024 11/02/2025 25,000,000
25,000,000
C
C
N
X
X
WCE78380203 (AOS)
WCF11238701 (WI)
11/02/2024
11/02/2024
11/02/2025
11/02/2025
X
1,000,000
1,000,000
1,000,000
City of South San Francisco is an is additional insured on the General Liability and Auto Liability if required by written/executed contract before a loss on a primary and non-contributory basis, including ongoing and completed operations. follows form over the General Liability, Auto Liability and Employers Liability. Waiver of Subrogation applies to the General Liability, Auto Liability and Workers Compensation if required by contract and where permitted by law.
City Clerk
City of South San Francisco
400 Grand Avenue
South San Francisco, CA
94080-0000
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Client#: 2059006 BAKERTAY
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