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HomeMy WebLinkAbout593124 HILLCREST SHOPS DBA SEAN & MELISSA BAUTISTA - INSURANCE CERTIFICATE (6)HILLC-1 TE(MM/ DIYY DATE (MM/DD/YYYY) 018 CERTIFICATE OF LIABILITY INSURANCE 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 559-897-5811 Kingsburg Insurance Agency License #0504756 P.O. Box 100 Kingsburg, CA 93631 Bruce A. Blayney CONTACT Lori Saubert NAM PHONE 559-897-5811 FAx 559-897-1663 (A/C, No, Ext): (A/C, No): E A . Isaubert@kingsburgins.com INSURERS AFFORDING COVERAGE NAIC # INSURER A: Admiral Insurance Company _ INSURED Hillcrest Shops INSURER B : State Compensation dba Sean & Melissa Bautista 6943 S. Reed INSURER C : `7 United Financial Casualty Co. 11770 INSURER D : Reedley„ CA 93654 INSURER E : INSURER F : CQVFRAGFS CFRTIFICATF Nl1MRFR- REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY Pr_:RICD 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 TYPE OF INSURANCE ADDL SUBR POLICY NUMBER POLICY EFF POLICY EXPLTR LIMITS A X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE [ 7X OCCUR Y CA000012270-11 12/18/2017 12/18/2018 EACH OCCURRENCE $ 1,000,000 DAMAGE TO RENTEDEMISES (Ea occurrencel $ 60,000 MED EXP (Any oneperson) $ 5,000 PERSONAL & ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER X POLICY F7PRO ❑ LOC JECT OTHER GENERAL AGGREGATE $ 2,000,000 PRODUCTS - COMP/OP AGG $ 2,000,060 C AUTOMOBILE LIABILITY ANY AUTO OWNED SCHEDULED AUTOS ONLY I AUTOS HIRED NON SWNEp AUTOS ONLY AUTOS ONLY y 08010166-6 05/26/2017 05/26/2018 ntSINGLE LIMIT COMBINED aaCCrdent) $ 1,000,000 BODILY INJURY Perperson) $ BODILY INJURY Per accident $ PROPERTY DAMAGE $ UMBRELLA LIAB EXCESS LIAB OCCUR EACH OCCURRENCE $ HCLAIMS-MADE AGGREGATE $ DED RETENTION $ B WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y/ ANY PROPRIETOR/PARTNER/EXECUTIVE ❑ OFFICER/MEMBER EXCLUDED? (Mandatory in NH) If yes, describe under DESCRiPTION OF OPERATIONS bei0w N / A 9098212-17 05/01/2017 05/01/2018 PER STATUTE I OTH- .L. EEACH ACCIDENT 1,000,000 $ E.L. DISEASE - EA EMPLOYEE $ 1,000,000 - DiSEASE - POLICY LIMIT 1 .00010U0 . 7 .)ESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) Re: Certificate holder is named as additional insured per GL forms CIS 20 10 04 13 & CG 20 37 04 13 attached and Auto form 1198 (01104) attached but only in regards to work completed by named insured for railroad amusement equipment work / 30 days notice of cancellation - 10 days for non payment of premium City of Fort Collins Attn: Marisa Donegon P.O. Box 580 Fort Collins, CO 80522 COFC-CO 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 REPRESENTATIV Bruce A. Blayney ` �,,� ArnRn,>s /gniam3i ©1988-2015 ACORD CORPORATION. All rigf is reserved. The ACORD name and logo are registered marks of ACORD