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HomeMy WebLinkAbout303367 CLEAN ENERGY - INSURANCE CERTIFICATE (9)ACOR" CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDD/YYYY) 1 11/21/2017 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 endorsements . PRODUCER Dodge Insurance Services, Inc. DBA: Arroyo Insurance Services 3510 Torrance Blvd Suite 305 CONTACT NAME: Ann Ta for -A PHONE , 310-356-8209 FAX AIC, . 310-316-1825 E-MAIL . annt@arroyoins.com INSURERS AFFORDING COVERAGE NAIC # Torrance CA 90503 INSURER A: Federal Insurance Co 120281 INSURED CLEAN-1 INSURER B: Pacific Indemnity Co. 120346 Clean Energy, A CA Corp. INSURERC:Ace Property & Casualty 20699 4675 MacArthur Court, Ste #800 Newport Beach CA 92660 INSURERD: INSURER E : INSURER F : COVERAGES CERTIFICATE NUMBER: 1132621695 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER POLICY EFF POLICY EXP MMIDD MMIDD/Y LIMITS A X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE �X OCCUR 100,000 Ded. 35816898 11/30/2017 11/30/2018 EACH OCCURRENCE $1,000,000 DAMAGE TO RENTED PREMISES Ea occurrence $1,000,000 X MED EXP (Any one person) $10,000 PERSONAL & ADV INJURY $1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: POLICY ] JECOT- � LOC OTHER: GENERAL AGGREGATE $2,000,000 PRODUCTS - COMPIOP AGG $2,000,000 $ A AUTOMOBILE X LIABILITY AINY AUTO OWNED SCHEDULED AUTOS ONLY AUTOS HIRED NON -OWNED AUTOS ONLY X AUTOS ONLY 73521989 11/30/2017 11/30/2018 COMBINED SINGLE L T Ea accident $ 1,000,00o BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ X PROPERTY DAMAGE Per accident $ Auto Liability Ded. $$5,000 A X UMBRELLA LIAB EXCESS LIAB HCLAIMS-MADE OCCUR 79860791 1 11/30/2017 11/30/2018 EACH OCCURRENCE $6,000,000 AGGREGATE $6,000,000 DED II 1 RETENTION $ $ B WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y / N ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? F_N] (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below N / A 71736418 11/30/2017 11/30/2018 PER OTH- X STATUTE ER STOP GAP E.L. EACH ACCIDENT $1,000,000 E.L. DISEASE - EA EMPLOYE $1,000,000 E.L. DISEASE - POLICY LIMIT 1 $1,000,000 C j Excess Liability G27923501003 11/30/2017 11/30/2018 Each Occurrence 8,000,000 Aggregate 8,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) RE: Site #590-Trans Fort/Ft. Collins - 117 N. Mason, Fort Collins, CO 80524. Endorsements apply if required by written contract. I-tK I IFIL A I t rIULUtK L ANL rLLA 1 IUN Trans Fort Ft Collins City's Director of Purchasing & Risk Management 215 N. Mason Fort Collins CO 80524 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE � © 1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016103) The ACORD name and logo are registered marks of ACORD CHUBBe Name & Mailing Address of the Insured CLEAN ENERGY, A CA CORPORATION 4675 MACARTHUR COURT, STE 800 NEWPORT BEACH CA 92660 FEIN 954603747 Name & Address of the Producer ARROYO INS, SERVICES, INC. (CASEY DODGE 3510 TORRANCE BL,, #305 TORRANCE CA 90503 Producer Number 9-06451 000 Attached to and Forming Part of Policy Number (17)7173-64-18 Policy Period 11/30/17 to 11/30/18 Effective Date 11/30/17 Name of Company PACIFIC INDEMNITY COMPANY N.C.C.I. Carrier Code 10685 Endorsement Number WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY NOTICE OF CANCELLATION OR NON -RENEWAL TO SPECIFIED PERSONS OR ORGANIZATIONS This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated. The following Condition is added to PART SIX - CONDITIONS: Notice Of Cancellation Or Non -Renewal To Specified Persons Or Organizations 1. If we cancel or non -renew this policy for any reason other than non-payment, we will deliver notice of the cancellation or non -renewal to any Person(s) or Organization(s) shown in the Schedule sixty (60) days prior to the effective date of cancellation or non -renewal. 2. If we cancel this policy for non-payment, we will deliver notice of the cancellation to any Persons or Organizations shown in the Schedule twenty (20) days prior to the effective date of cancellation. 3. If notice is mailed, proof of mailing will be sufficient proof of notice. 4. Any failure by us to notify such person(s) or organization(s) will not invalidate such cancellation or non - renewal with respect to any other person(s) or organization(s). SCHEDULE Name(s) and Address(es): "This endorsement is not applicable for use in the states of Arizona and Florida" Issue Date 11/21/17 LAO ERG 146 WC 99 06 08 (Rev. 5-88) (Formerly 08-02-0035)