certificate of liability insurance - Mt. Diablo Unified School District
certificate of liability insurance - Mt. Diablo Unified School District
certificate of liability insurance - Mt. Diablo Unified School District
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COMMERCIAL GENERAL LIABILITY<br />
CLAIMS-MADE<br />
GEN'L AGGREGATE LIMIT APPLIES PER:<br />
X PRO-<br />
POLICY JECT LOC<br />
AUTOMOBILE LIABILITY<br />
UMBRELLA LIAB<br />
EXCESS LIAB<br />
CERTIFICATE OF LIABILITY INSURANCE<br />
OCCUR<br />
OCCUR<br />
CLAIMS-MADE<br />
EACH OCCURRENCE $<br />
DAMAGE TO RENTED<br />
PREMISES (Ea occurrence) $<br />
MED EXP (Any one person) $<br />
PERSONAL & ADV INJURY $<br />
GENERAL AGGREGATE $<br />
PRODUCTS - COMP/OP AGG $<br />
EACH OCCURRENCE $<br />
AGGREGATE $<br />
$<br />
DATE (MM/DD/YYYY)<br />
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS<br />
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES<br />
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED<br />
REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER.<br />
IMPORTANT: If the <strong>certificate</strong> holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to<br />
the terms and conditions <strong>of</strong> the policy, certain policies may require an endorsement. A statement on this <strong>certificate</strong> does not confer rights to the<br />
<strong>certificate</strong> holder in lieu <strong>of</strong> such endorsement(s).<br />
LIC #0726293<br />
1-415-391-1500<br />
CONTACT<br />
PRODUCER<br />
Gallagher Construction Services/<br />
Arthur J. Gallagher & Co. Insurance Brokers <strong>of</strong> CA Inc.<br />
1 Market St., Spear Tower #200<br />
San Francisco, CA 94105<br />
INSURED<br />
Meehleis Modular Buildings, Inc.<br />
1303 East Lodi Avenue<br />
Lodi, CA 95240<br />
COVERAGES CERTIFICATE NUMBER: 29804038<br />
REVISION NUMBER:<br />
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD<br />
INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS<br />
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,<br />
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.<br />
INSR<br />
ADDL SUBR<br />
POLICY EFF POLICY EXP<br />
LTR TYPE OF INSURANCE INSR WVD<br />
POLICY NUMBER<br />
(MM/DD/YYYY) (MM/DD/YYYY)<br />
LIMITS<br />
A GENERAL LIABILITY<br />
X X 51UENOH1209<br />
07/01/13<br />
A<br />
B<br />
C<br />
X<br />
X<br />
X<br />
X<br />
ANY AUTO<br />
ALL OWNED<br />
AUTOS<br />
HIRED AUTOS<br />
X<br />
SCHEDULED<br />
AUTOS<br />
NON-OWNED<br />
AUTOS<br />
DED RETENTION $<br />
WORKERS COMPENSATION<br />
AND EMPLOYERS' LIABILITY<br />
Y / N<br />
ANY PROPRIETOR/PARTNER/EXECUTIVE<br />
OFFICER/MEMBER EXCLUDED<br />
N / A<br />
(Mandatory in NH)<br />
If yes, describe under<br />
DESCRIPTION OF OPERATIONS below<br />
X<br />
X<br />
X<br />
X<br />
X<br />
51UENOH1210<br />
SF12EXC757805IV<br />
51WEOH1208<br />
NAME:<br />
PHONE<br />
(A/C, No, Ext):<br />
E-MAIL<br />
ADDRESS:<br />
INSURER A :<br />
INSURER B :<br />
INSURER C :<br />
INSURER D :<br />
INSURER E :<br />
INSURER F :<br />
07/01/12<br />
INSURER(S) AFFORDING COVERAGE<br />
HARTFORD FIRE IN CO<br />
NAVIGATORS INS CO<br />
TWIN CITY FIRE INS CO CO<br />
07/01/12 07/01/13<br />
COMBINED SINGLE LIMIT<br />
(Ea accident)<br />
$<br />
BODILY INJURY (Per person) $<br />
BODILY INJURY (Per accident) $<br />
PROPERTY DAMAGE<br />
$<br />
(Per accident)<br />
WC STATU-<br />
X TORY LIMITS<br />
E.L. EACH ACCIDENT<br />
FAX<br />
(A/C, No):<br />
Comp Ded : $250<br />
07/01/12 07/01/13<br />
07/01/12 07/01/13<br />
OTH-<br />
ER<br />
$<br />
E.L. DISEASE - EA EMPLOYEE $<br />
E.L. DISEASE - POLICY LIMIT $<br />
$<br />
$<br />
10/23/2012<br />
29459<br />
NAIC #<br />
19682<br />
42307<br />
1,000,000<br />
500,000<br />
10,000<br />
1,000,000<br />
2,000,000<br />
2,000,000<br />
1,000,000<br />
Coll Ded : $500<br />
4,000,000<br />
4,000,000<br />
1,000,000<br />
1,000,000<br />
1,000,000<br />
DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required)<br />
RE: All Operations<br />
ADDITIONAL INSURED(S): <strong>Mt</strong>. <strong>Diablo</strong> <strong>Unified</strong> <strong>School</strong> <strong>District</strong>, its <strong>of</strong>ficers, <strong>of</strong>ficials, agents, employees and<br />
volunteers with respect to <strong>liability</strong> out <strong>of</strong> automobiles owned, leased, hired or borrowed on behalf <strong>of</strong> the contractor<br />
CERTIFICATE HOLDER<br />
RE: All Operations<br />
<strong>Mt</strong>. <strong>Diablo</strong> <strong>Unified</strong> <strong>School</strong> <strong>District</strong><br />
3333 Ronald Way<br />
Concord, CA 94519<br />
ACORD 25 (2010/05)<br />
ranshargcs<br />
29804038<br />
USA<br />
CANCELLATION<br />
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE<br />
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN<br />
ACCORDANCE WITH THE POLICY PROVISIONS.<br />
AUTHORIZED REPRESENTATIVE<br />
© 1988-2010 ACORD CORPORATION. All rights reserved.<br />
The ACORD name and logo are registered marks <strong>of</strong> ACORD
51WEOH1208<br />
07/01/2012<br />
Meehleis Modular Buildings, Inc.<br />
1303 E. Lodi Avenue<br />
Lodi, CA 95240-0840<br />
07/01/2013
SUPPLEMENT TO CERTIFICATE OF INSURANCE<br />
DATE<br />
10/23/2012<br />
NAME OF INSURED: Meehleis Modular Buildings, Inc.<br />
Additional Description <strong>of</strong> Operations/Remarks from Page 1:<br />
Additional Information:<br />
General Liability<br />
Additional Insured Endorsement Form: CG20100704 & CG20370704<br />
Primary Insurance Endorsement Form: 90533<br />
Waiver <strong>of</strong> Subrogation Endorsement Form: CG24041093<br />
Automobile:<br />
Additional Insured Endorsement Form: 87950<br />
Waiver <strong>of</strong> Subrogation - Blanket endorsement form 62897<br />
Workers' Compensation:<br />
Waiver <strong>of</strong> Subrogation - Form WC 040361<br />
The Producer will endeavor to mail 30 days written notice to the Certificate Holder named on the<br />
<strong>certificate</strong> if any policy listed on the <strong>certificate</strong> is cancelled prior to the expiration date.<br />
Failure to do so shall impose no obligation or <strong>liability</strong> <strong>of</strong> any kind upon the Producer or otherwise<br />
alter the policy terms.<br />
SUPP (05/04)