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HomeMy WebLinkAbout2009-10 Sanitary District No. 5CERTIFICATE OF COVERAGE 21-Dec-2009 PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OAF EVIDENCE ONLY AND CONFERS Alliant Insurance Services Inc. NO RIGHTS UPON THE CERTIFICATE HOLD T E , 100 Pine Street AMEND, EXTEND OR ALTER THE COVERAG RD D H L pl I 11 th Floor BELOW. ; San Francisco, CA 94111 (415) 403-1400 4 INSURED San t ry,,Q(S MafItl-County M of CSRMA I P.O. Box 227 Tilb" CA 94920 T r f , r- t o . p~ . ( t o ' 8 , - , . U t 172 MEMORANDUM OF COVERAGE NUMBER PROGRAM AFFORDING COVERAGE CSL SD 5 0910 1 California Sanitation Risk Management Authority (C.S.R.M.A.) THIS IS TO CERTIFY THAT THE COVERAGE IS AFFORDED TO THE ABOVE NAMED MEMBER, AS PROVIDED BY THE MEMORANDUM(S) OF COVERAGE, FOR THE COVERAGE PERIOD SHOWN BELOW, NOTHWITHSTAN DING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN. THE COVERAGE AFFORDED BY THE PROGRAM DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS, AND CONDITIONS OF SUCH MEMORANDUM(S) OF COVERAGE. THE FOLLOWING COVERAGE IS IN EFFECT: PUBLIC ENTITY LIABILITY IS DEFINED IN THE MEMORANDUM(S) OF COVERAGE ON FILE WITH THE ENTITY, AND COPIES ARE AVAILABLE ON REQUEST. Type Of Coverage: EffectiveDate ExpirationDate S.I.R. Deductible Liability Limit Per Public Entity Liability Including Occurrence General Liability (Coverage) General Liability 31-Dec-2009 31-Dec-2010 - $10,000 $15,000,000 Products/Completed Operations Contractual Liability Automobile Liability (Coverage) Non-Owned Automobiles 31-Dec-2009 31-Dec-2010 - $10,000 $15,000,000 Owned Automobiles Hired and Non-Owned Auto DESCRIPTION OF OPERATIONS/LOCATIONSNEHICLES/EXCLUSIONS ADDED BY ENDORSEMENTS/SPECIAL PROVISIONS THE HOLDER IS NAMED AS AN ADDITIONAL COVERED PARTY PER THE MEMORANDUM OF COVERAGE WITH RESPECTS TO THE USE OF PREMISES DURING THE POLICY TERM. COPIES OF THE MEMORANDUM OF COVERAGE ARE AVAILABLE UPON REQUEST. CERTIFICATE HOLDER - _ - CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE TIBURON TOWN CLERK 15366- 382 EXPIRATION DATE THEREOF, THE ISSUING COMPANY WILL ENDEAVOR TO MAIL 30 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE COMPANY , 1505 TIBURON BOULEVARD ITS AGENTS OR REPRESENTATIVES. TIBURON, CA 94920 AUTHORIZED REPRESENTA /27/20009 R) A CORD CERTIFICATE OF LIABILITY INSURANCE Date TM PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HEFFERNAN PROFESSIONAL PRACTICES HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR License Number: 0564249 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. 1855 W. Katella Avenue, Suite 255 Orange, CA 92867 INSURERS AFFORDING COVERAGE NAIC # INSURED INSURER A: Travelers Property Casualty Co of Am 36161 ALTA PLANNING AND DESIGN, INC. INSURER B: Travelers Indemnity Company 25658 711 SE GRAND AVENUE INSURER C: Travelers Casualty Ins Co. of America 19046 OR 97214 PORTLAND INSURER D: Continental Casualty Company 20443 , INSURER E: COVERAGES 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 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. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR LTR ADD'L INSRD TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE DATE MM/DD POLICY EXPIRATION DATE (MWDDNY) LIMITS B GENERAL LIABILITY 6800653P383 06/01/09 06/01/10 EACH OCCURRENCE $1,000,000 A X COMMERCIAL GENERAL LIABILITY 6800666P70A 06/01/09 06/01/10 DAMAGE TO RENTED PREMISES Es. Occurrence $1,000,000 CLAIMS MADE X OCCUR MED EXP (ANY ONE PERSON) $10,000 PERSONAL & ADV INJURY $1,000,000 GENERAL AGGREGATE $2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER PRODUCTS - COMP/OP AGG) $2,000,000 POLICY X PRO- JECT LOC B A AUTOMOBILE LIABILITY ANY AUTO 6800653P383 6800666P70A 06/01/09 06/01/09 06/01/10 06/01/10 COMBINED SINGLE LIMIT (Ea accident) $1,000,000 ALL OWNED AUTOS BODILY INJURY $ SCHEDULED AUTOS (Per person) X HIRED AUTOS BODILY INJURY $ X NON-OWNED AUTOS (Per accident) PROPERTY DAMAGE $ (Per Accident) GARAGE LIABILITY AUTO ONLY - EA ACCIDENT $ ANY AUTO OTHER THAN EA ACC $ E AUTO ONLY: AGG $ A EXCESS/UMBRELLA LIABILITY EACH OCCURRENCE $ 1,000,000 X OCCUR ❑ CLAIMS MADE CUP3324T848 06/01/09 06/01/10 AGGREGATE $ 1,000,000 $ DEDUCTIBLE $ RETENTION $ 10,000 $ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY UB7125Y672 09/01/09 09/01/10 WC STATU- OTH- X TORY LIMITS ER C ANY PROP IETOR/PARTNER/EXECUTIVE EL EACH ACCIDENT $1,000,000 OFFICER/MEMBER EXCLUDED? EL DISEASE - POLICY LIMIT $1,000,000 If yes, describe under SPECIAL PROVISIONS below EL DISEASE - EA EMPLOYEE $1,000,000 D OTHER Professional Liability MCH114135257 10/17/09 10/17/10 $2,000,000 Per Claim $2,000,000 Aggregate DESCRIPTION OF OPERATIONS/LOCATIONSNEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS Projects as on file with the insured including but not limited to Share the Path Program. City of Tiburon is named as additional insured on general liability policy-see attached endorsement. XX CERTIFICATE HOLDER L:ANL;hLLAI IUN ,U UaV Notice Tor Non-ravment OT F'reMIUm SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL N06A T= MAIL 30' DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, OUT rA11 r loc TO nn en SW Al I City of Tiburon IMPOSE 010 031 1GATIGINI OR 1 IA~11 ITV AC A\IV Ill\11111~A\I TLJG 1\I CIIOC~ ITC Af^C\ITC AO OCl1~C CC\ITATI\/CC CVf^C~T CAD /~wAl /~Cl 1 ATIA AI r111C T/1 AIAAI OAV\ACAIT l1L OO CII II lAA IN \A WIGW Attn: Diane Crane lacopi 1505 Tiburon Blvd. l`wc~c A ~f11fAVCI \IATI/ GIAIII I OG /~1\/C\I Tiburon, CA 94920 AUTHORIZED REPRESENTATIVE ACORD 25 (2001/08) ©ACORD CORPORATION 1988 POLICY NO.: 6800666P70A / 6800653P383 COMMERCIAL GENERAL LIABILITY THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. BLANKET ADDITIONAL INSURED (ARCHITECTS, ENGINEERS AND SURVEYORS) This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART A. The following is added to WHO IS AN INSURED (Section II): Any person or organization that you agree in a "contract or agreement requiring insurance" to include as an additional insured on this Coverage Part, but only with respect to liability for "bodily injury", "property damage" or "personal injury" caused, in whole or in part, by your acts or omissions or the acts or omissions of those acting on your behalf: a. In the performance of your ongoing operations; b. In connection with premises owned by or rented to you; or c. In connection with "your work" and included within the "products-completed operations hazard". Such person or organization does not qualify as an additional insured for "bodily injury", "property damage" or "personal injury" for which that person or organization has assumed liability in a contract or agreement. The insurance provided to such additional insured is limited as follows: d. This insurance does not apply on any basis to any person or organization for which coverage as an additional insured specifically is added by another endorsement to this Coverage Part. e. This insurance does not apply to the rendering of or failure to render any "professional services". f. The limits of insurance afforded to the additional insured shall be the limits which you agreed in that "contract or agreement requiring insurance" to provide for that additional insured, or the limits shown in the Declarations for this Coverage Part, whichever are less. This endorsement does not increase the limits of insurance stated in the LIMITS OF INSURANCE (Section III) for this Coverage Part. B. The following is added to Paragraph a. of 4. Other Insurance in COMMERCIAL GENERAL LIABILITY CONDITIONS (Section IV): However, if you specifically agree in a "contract or agreement requiring insurance" that the insurance provided to an additional insured under this Coverage Part must apply on a primary basis, or a primary and non- contributory basis, this insurance is primary to other insurance that is available to such additional insured which covers such additional insured as a named insured, and we will not share with the other insurance, provided that: (1) The "bodily injury" or "property damage" for which coverage is sought occurs; and (2) The "personal injury" for which coverage is sought arises out of an offense committed; after you have entered into that "contract or agreement requiring insurance". But this insurance still is excess over valid and collectible other insurance, whether primary, excess, contingent or on any other basis, that is available to the insured when the insured is an additional insured under any other insurance. C. The following is added to Paragraph 8. Transfer Of Rights Of Recovery Against Others To Us in COMMERCIAL GENERAL LIABILITY CONDITIONS (Section IV): We waive any rights of recovery we may have against any person or organization because of payments we make for "bodily injury", "property damage" or "personal injury" arising out of "your work" performed by you, or on your behalf, under a "contract or agreement requiring insurance" with that person or organization. We waive these rights only where you have agreed to do so as part of the "contract or agreement requiring insurance" with such person or organization entered into by you before, and in effect when, the "bodily CG D3 81 09 07 © 2007 The Travelers Companies, Inc. Page 1 of 2 Includes copyrighted material of Insurance Services Office, Inc., with its permission. injury" or "property damage" occurs, or the "personal injury" offense is committed. D. The following definition is added to DEFINITIONS (Section V): "Contract or agreement requiring insurance" means that part of any contract or agreement under which you are required to include a person or organization as an additional insured on this Coverage Part, provided that the "bodily injury" and "property damage" occurs, and the "personal injury" is caused by an offense committed: a. After you have entered into that contract or agreement; b. While that part of the contract or agreement is in effect; and c. Before the end of the policy period. CG D3 81 09 07 © 2007 The Travelers Companies, Inc. Page 2 of 2 Includes copyrighted material of Insurance Services Office, Inc., with its permission. ACORD TM CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YY) 1/20/2010 PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE Cossio Insurance Agency HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE PO Box 188 COVERAGE AFFORDED BY THE POLICIES BELOW Simpsonville, SC 29681 (864) 688-0121 I INSURERS AFFORDING COVERAGE INSURED INSURED A: Interstate Fire & Casualty Company INSURED B: _ Jubilee Jumps, Inc - P. O. Box 1745 INSURED C: Windsor, CA 95492 INSURED D: INSURED E: COVERAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIRMENT. TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WIHT 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 AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF POLICY POLICY NUMBER POLICY EFFECTIVE POLICY EXP LIMITS LTR DATE (MM/DD/Y Y) DATE (MM/DD/YY) GENERAL LIABILITY _ Hired and Non Owned Auto $1 000 000 LX] COMMERCIAL GENERAL LIABILITY Per Occurrence , , $1,000,000 CLAIMS MADE ~ X OCCUR Aggregate $2,000,000 A n Products/ Completed Operations Aggn $1,000,000 Personal and Advertising Injury $1,000,000 n SFE1000964 1/28/2010 1/28/2011 Employee Benefits $1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER Fire Damage Medical Expenses $100,000 Excluded U POLICY -J PRO- _J LOC Self Insured Retention $2,500 JECT AUTOMOBILE LIABILITY n ANY AUTO U ALL OWNED AUTOS U SCHEDULED AUTOS HIRED AUTOS NON-OWNED AUTOS LJ GARAGE LIABILITY ANY AUTO EXCESS LIABILITY n OCCUR CLAIMS MADE j DEDUCTIBLE RETENTION $ WORKERS COMPENSATION AND EMPLOYER'S LIABILITY OTHER COMBINED SINGLE LIMIT (Ea accident) BODILY INJURY (Per Person) BODILY INJURY (Per accident) PROPERTY DAMAGE (Per accident) AUTO ONLY - EA ACCIDENT $ OTHER THAN EA ACC $ AUTO ONLY. AGG $ EACH OCCURRENCE $ AGGREGATE $ WC STATU- OTH- TORY LIMITS 1- -ER E.L. EACH ACCIDENT E.L. DISEASE - EA EMPLOYEE $ E.L. DISEASE - POLICY LIMIT $ DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISION Jumps_Bounce Houses Operations located at 1400 Petaluma Hill Rd Santa Rosa, CA 95404 Certificate Holder As Additional Insured Amusements devices on file with company for special events dated throughout policy period. CERTIFICATE HOLDER: CANCELLATION Town of Tiburon SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED Ann Danforth BEFORE THE EXPIRATION DATE THREOF, THE ISSUING INSURER WILL 1505 Tiburon Blvd. ENDEAVOR TO MAIL 30 DAYS WRITTEN NOTICE TO THE CERTIFICATE Tiburon, CA 94920 HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY IN N THE INSURER, IT'S AGENTS OR REPRESNETATIVES AUTHORIZED REPRESENTATIVE ACORD 25 (2001/08) ►coRD® CERTIFICATE OF LIABILITY INSURANCE DATE( YYYY) 12/21/09 1/09 PRODUCER 0726293 1-415-546-9300 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Arthur J. Gallagher & Co. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE Insurance Brokers of California, Inc., License #0726293 HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR One Market Plaza, Spear Tower ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Suite 200 San Francisco, CA 94105 INSURERS AFFORDING COVERAGE NAIC # INSURED INSURER A: ORDINARY MUT RRG CORP 10171 Roman Catholic Archbishop of San Francisco INSURER B: HARTFORD FIRE IN CO 19682 One Peter Yorke Way INSURER C: F i CA 94109 S INSURER D: ranc an sco, INSURER E: COVERAGES 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. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR DD'L TYPE OF INSURANQF POLICY NUMBER OLICY EFFECTIVE P DATE (MM/DD1YYYY) POLICY EXPIRATION DATE (MM/DD/YYYY) LIMITS A GENERAL LIABILITY CGAL0022009 07/01/09 07/01/10 EACH OCCURRENCE $ 1,000,000 7C COMMERCIAL GENERAL LIABILITY IIA-MAGE TO RENTED PREMISES Ea occurrence $ 1,000,000 CLAIMS MADE XI OCCUR MED EXP (Any one person) $ 5,000 PERSONAL & ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP/OP AGG $2,000,000 X POLICY PRO LOC Liquor Liability 1,000 000 A AUT OMOBILE LIABILITY CGAL0022009 07/01/09 07/01/10 COMBINED SINGLE LIMIT 000 000 $ 1 X ANY AUTO (Ea accident) , , X ALL OWNED AUTOS BODILY INJURY $ X SCHEDULED AUTOS (Per person) X HIRED AUTOS BODILY INJURY $ X NON-OWNED AUTOS (Per accident) PROPERTY DAMAGE (Per accident) $ GARAGE LIABILITY AUTO ONLY - EA ACCIDENT $ ANY AUTO OTHER THAN EA ACC $ AUTO ONLY: AGG $ EXCESS / UMBRELLA LIABILITY EACH OCCURRENCE $ 1 OCCUR F-1 CLAIMS MADE AGGREGATE $ $ DEDUCTIBLE $ RETENTION $ $ B WORKERS COMPENSATION ' 57WEFX4185 O1/O1/10 O1/O1/11 X WC STATU- OTH- ~ TORY LIMITS ER AND EMPLOYERS LIABILITY Y/N 000 1 000 ANY PROPRIETOR/PARTNER/EXECUTIVE E.L. EACH ACCIDENT , , $ ❑ OFFICER/MEMBER EXCLUDED? (Mandatory in NH) E.L. DISEASE - EA EMPLOYE $ 1, 000, 000 If yes, describe under SPECIAL PROVISIONS below E.L. DISEASE - POLICY LIMIT $ 1 000 000 OTHER A Counselors E&O Liability CGAL0022009 07/01/09 07/01/10 Per Claim 1,000,000 Claims-Made Form Aggregate 3,000,000 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES / EXCLUSIONS ADDED BY ENDORSEMENT / SPECIAL PROVISIONS RE: St. Hilary School, 761 Hilary Dr., Tiburon, CA 94920. As respects St. Hilary School Field Day on June 11, 2010. CERTIFICATE HOLDER CANCELLATION *TEN DAY NOTICE FOR NON-PAYMENT OF PREMIUM Town of Tiburon and their officers, agents and employees 1505 Tiburon Blvd. Tiburon, CA 94920 USA SHOULD ANY OF THEABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL *30 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR REPRESENTATIVES. AUTHORIZED REPRESENTATIVE ACORD 25 (2009/01) wloi 13907593 © 1988-2009 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD IMPORTANT If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). 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). DISCLAIMER This Certificate of Insurance does not constitute a contract between the issuing insurer(s), authorized representative or producer, and the certificate holder, nor does it affirmatively or negatively amend, extend or alter the coverage afforded by the policies listed thereon. AcUF<U Z5 (2009/01) 3:4 ~coRO® CERTIFICATE OF LIABILITY INSURANCE DATE( YYYY) 12/21/09 1/09 PRODUCER 0726293 1-415-546-9300 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Arthur J. Gallagher & Co. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE Insurance Brokers of California, Inc., License #0726293 HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR Spear Tower One Market Plaza ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. , Suite 200 San Francisco, CA 94105 INSURERS AFFORDING COVERAGE NAIC # INSURED INSURER A: ORDINARY MUT RRG CORP 10171 Roman Catholic Archbishop of San Francisco INSURER B: HARTFORD FIRE IN CO 19682 One Peter Yorke Way INSURER C: CA 94109 i INSURER D: San Franc sco, INSURER E: COVERAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR ANY REQUIREMENT , MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR DD'L TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE DATE (MM/DD/YYYY) POLICY EXPIRATION DATE (MM/DD/YYYY) LIMITS A GENERAL LIABILITY CGAL0022009 07/01/09 07/01/10 EACH OCCURRENCE $ 1,000,000 X COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED PREMISES Ea occurrence $ 1,000,000 CLAIMS MADE 7XI OCCUR MED EXP (Any one person) $ 5,000 PERSONAL &ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 EN-L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP/OP AGG $ 2 , 000 , 000 K POLICY PRO LOC Liquor Liability 1,000 000 A AUT OMOBILE LIABILITY CGAL0022009 07/01/09 07/01/10 COMBINED SINGLE LIMIT $ 1 000 000 X ANY AUTO (Ea accident) , , X ALL OWNED AUTOS BODILY INJURY $ X SCHEDULED AUTOS (Per person) X HIRED AUTOS BODILY INJURY $ X NON-OWNED AUTOS (Per accident) PROPERTY DAMAGE (Per accident) $ GARAGE LIABILITY AUTO ONLY - EA ACCIDENT $ ANY AUTO OTHER THAN EA ACC $ AUTO ONLY. AGG $ EXCESS / UMBRELLA LIABILITY EACH OCCURRENCE $ 7 OCCUR F-1 CLAIMS MADE AGGREGATE $ DEDUCTIBLE $ RETENTION $ $ B WORKERS COMPENSATION 57WEFX4185 O1/O1/10 O1/Ol/11 OTH- I X WC STATU- I TORY LIMITS I ER AND EMPLOYERS' LIABILITY Y/N ANY PROPRIETOR/PARTNER/EXECUTIVE E.L. EACH ACCIDENT $ 1,000,000 ❑ OFFICER/MEMBER EXCLUDED? (Mandatory in NH) E.L. DISEASE - EA EMPLOYE $ 1,000,000 If yes, describe under SPECIAL PROVISIONS below E.L. DISEASE - POLICY LIMIT $ 1 000 000 OTHER A Counselors E&O Liability CGAL0022009 07/01/09 07/01/10 Per Claim 1,000,000 Claims-Made Form Aggregate 3,000,000 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES / EXCLUSIONS ADDED BY ENDORSEMENT / SPECIAL PROVISIONS RE: St. Hilary School, 765 Hilary Drive, Tiburon, CA 94920. As respects St. Hilary Flag Football practice and games fro September 2009 to November 2009 and Girls Soccer practices and games from March 2010 to May 2010. CERTIFICATE HOLDER CANCELLATION *TEN DAY NOTICE FOR NON-PAYMENT OF PREMIUM Town of Tiburon and their officers, agents and employees 1505 Tiburon Blvd. Tiburon, CA 94920 USA SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL *30 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR REPRESENTATIVES. AUTHORIZED REPRESENTATIVE / i ACORD 25 (2009/01) wloi 13907591 ©1988-2009 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD IMPORTANT If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). 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). DISCLAIMER This Certificate of Insurance does not constitute a contract between the issuing insurer(s), authorized representative or producer, and the certificate holder, nor does it affirmatively or negatively amend, extend or alter the coverage afforded by the policies listed thereon. ACORD 25 (2009/01) 3:4 ACORD CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) TM 9/18/2009 PRODUCER Phone: 973-467-8005 Fax: 973-921-2876 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Bollinger Insurance ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE 101 JFK Parkway HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Short Hills NJ 07078 INSURERS AFFORDING COVERAGE NAIC # INSURED INSURER A: Philade l hia Indemnity Ins Co 8058 California Youth Soccer INSURERB:AIG Life 1040 Serpentine L, Suite 201 Pleasanton CA 94566 INSURER C: INSURER D: INSURER E: COVERAGES 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. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR LTR DD'L NSRD TYPE F INSURANCE POLICY NUMBER POLICY EFFECTIVE DATE MM/DD/YY POLICY EXPIRATION DATE MM/DD/YY LIMITS A X GENERAL LIABILITY PHPK4 619 6 2 9/1/2009 9/1/2010 EACH OCCURRENCE $1,000,000 DAMAGE TO RENTED X COMMERCIAL GENERAL LIABILITY PREMISES Ea occurence $1 000 000 CLAIMS MADE X OCCUR MED EXP (Any one person) $ 5 000 X T n c-1 Part- L i a PERSONAL B ADV INJURY $ 1 000, 000 GENERAL AGGREGATE $ 5 000, 000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP/OP AGG $ 2 000, 000 POLICY PRO LOC JECT A AUT OMOBILE LIABILITY PHPK4 619 6 2 9/ 1/ 2 009 9/1/2010 COMBINED SINGLE LIMIT 5 1, 000, 000 ANY AUTO ALL OWNED AUTOS SCHEDULED AUTOS 6 X HIREDAUTOS X y NON-OWNEDAUTOS Ct GA RAGE LIABILITY l 1 5 U'Z I~ ~a C~ ..l L; > ,G~' GL f~ Vl l G. ANY AUTO i EXCESS/UMBRELLA LIABILITY i OCCUR CLAIb ~ / / ~ L IJ~''~'~! ' ~L ~ . ' ~ ! (J i DEDUCTIBLE RETENTION $ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANY PROP RIETOR/PARTNER/EXECUTI OFFICER/MEMBER EXCLUDED? If yes, describe under SPECIAL PROVISIONS below B OTHER SRG91225873 9/1/2009 9/1/2010 Medical Max: $300,000 Accident Coverage ed: $250/Claim Full Excess DESCRIPTION OF OPERATIONS / LOCATIONS /VEHICLES / EXCLUSIONS ADDED BY ENDORSEMENT / SPECIAL PROVISIONS 11 operations of CYSA North, its youth member teams, & leagues- The certificate holder is named as an additional insured with respects to the liability coverage.THIS CERTIFICATE IS VALID ONLY FOR CYSA-NORTH SANCTIONED VENTS/ACTIVITIES. Certificate is issued on behalf of IBURON PENINSULA SOCCER CLUB Group Code: 5-06 CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING INSURER TOWN OF TIBURON WILL ENDEAVOR TO MAIL 30 DAYS WRITTEN NOTICE TO THE INCLUDING ALL FIELDS, GROUNDS AND BUILDINGS CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO 1505 TIBURON BLVD. SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON TIBURON CA 94920 THE INSURER, ITS AGENTS OR REPRESENTATIVES. AUTHORIZED REPRESENTATIVE ACORD 25 (2001108) - f ©ACORD CORPORATION 1988 'gh -ills -,x s ~h Ub Soccer LV $Aa ernue North each SC 29577 AGE INSURER `-kade1 uom an ••..~c;~r S C: hia Insuranc 8970 ICIIS pF INSURER D: e Corn an 38 50 ATE M AG ANY DEQUIR~STED BELOW HAVE INSURERS XCLusroxBE ISSUED OR EA' TE BEEN ISS S AND CONDITI NS MFR CN• CTS INSN OFCEYCONTRACT INSURED NAM H POLICIES. AGG AFFOpR OTHER DoORTHE p SEC L►TY H ~~YNUMBER G'~ LIMITS S OWN LICIRS I PERIOD I DES TH . RESPEC'~T C ERCI GENERALLI P PK5103p UCYEFFE MAY HAVE C'RIBED TO Wn ICATEDABIL , PUT CAMS MADE OCCUITY R 6 1 /1 /2 O 1 po EEN REDUC R RED PA SDUB jE T IMSTHIS o ALL THE EACH OCCURRENCE UMiTS 1 AGGREGATE LIMB PRFUIt, $ 7 °OLICY PRO- -HIES PER. MOBILE U,4 LOC VYAUTO L O*NED AU-rOS HEDULEDAUTOS EDAUTOS I _OWNEDAUTOS ABIjry JTO IRELLA U,4M 1TY CLAIMS MADE PHLTB293506 ILE N $ ITR*AND F U CUTNE DED? E DED? 'Ioyy ice 4102AH235479 1/1/201p 141/2011 LocA 1 /1 /2 010 1/1/2011 'r is named CLES/EXCWSIONs as an addi BYEIVDpRg `er Passcard holders part al insure durF-Nr derF'EGALPROONs Participating in Marin the FC ~llity policy. C1 ub ID #431, MED pip (Artygl@ ) $ PERSONAL $ ADY INJURY GENES AGG $ REGA7F PRODUCTS -COMP/OP $ 1 1 h AGG s - COMBINED (Ea a~ INGLE LIMIT BODI RY (Per pew) (P~I LURY $ (Perna ddeWj AMAGE $ AUTO ONLY- EA ACCIDE. A ER THAN EA $ OONLY: ACC $ EACH OCCURRENCE AGG $ AGG TE $ $ a EL EACHACCT E.C. DISEASE EA EMPLOYE E-L DISEASE _ POLICY IrMIT ed Max: °d: V Limit: :emit: s $loo, o $500 $2,000 $1, 000 This certificate is issue on troll CgNCE~I71SHOULD Ailirl! 0 4 -920 d BEFORE 11, 11" OF 7TOjqAjL ABOVE WILL, EWDEAt, XION DATE ATE j'OLI C TI S EHAI,j, I ATE HOLDER <30> DATjjRR YS ,,OP THEI SSUE CANCELLED ED To OITT: r 1V THE INSURER E O OBLIGATI ON O THE EFT B NOTICE G INSURER LlAj3 THE AUTNOt AGENTS OR REPR SLATYOF ANY KEVD DO SO TM E y VES. UPON ISSUE DATE (MM/DD/YY) CERTIFICATE OF INSURANCE 2/23/10 PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND Alliant Insurance Services, Inc. CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES 1301 Dove St., Suite 200 NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES Newport Beach, CA 92660 BELOW. (800) 821-9283 Ext. 8161 • Fax (949) 756-2713 COMPANIES AFFORDING COVERAGE INSURED SPECIAL LIABILITY INSURANCE PROGRAM (SLIP) MEMBER PANY A ALLIED WORLD NATIONAL ASSURANC LETTER 14'Ty MARIN ENERGY COMPANY A ~ V92 r- `c~C~ VE, 08 LETTER B SAN RAFAEL, CA 94903 LE MPANY A C MA ER COMPANY D LETTER OFFICE NY E TOWN OF TIBURON TT LE ER COVERAGES 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 CO NTRACT 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, EXCLUSION AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. CO LTR TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATION LIMITS DATE (MM/DD/YY) DATE MM/DDNY A GENERAL LIABILITY C010407/002 01/28/10 09/29/10 GENERAL AGGREGATE NA* X COMMERCIAL GENERAL LIABILITY PRODUCTS-COMP/OP $2 000 000 CLAIMS OCCUR lx:l , , AGG. PERSONAL & ADV. INJURY $2 000 000 MADE , , OWNER'S & CONTRACTOR'S EACH OCCURRENCE $2 000 000 PROT._ , , X GL Ded: $1,000 DED FIRE DAMAGE (Any one ~ $1 000 000 , , fire MED. EXPENSE (Any one N/A person) AUTOMOBILE LIABILITY COMBINED SINGLE ANY AUTO ALL OWNED AUTOS h LIMIT Y BODILY INJURY SCHEDULED AUTOS , (Per person) HIRED AUTOS BODILY INJURY NON-OWNED AUTOS (Per accident) GARAGE LIABILITY - PROPERTY DAMAGE i EACH OCCURRENCE UMBRELLA FORM AGGREGATE OTHER THAN UMBRELLA FORM ~ STATUTORY LIMITS WORKER'S COMPENSATION EACH ACCIDENT AND DISEASE-POLICY LIMIT EMPLOYER'S LIABILITY DISEASE-EACH DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES/SPECIAL ITEMSC *POLICY FORM DOES NOT CONTAIN A GENERAL LIABILITY AGGREGATE AS RESPECTS TO THE OPERATIONS OF THE NAMED INSURED, CERTIFICATE HOLDER SHALL BE NAMED ADDITIONAL INSURED. ADDITIONAL INSURED ENDORSEMENT ATTACHED. SUBJECT TO POLICY TERMS, CONDITIONS AND EXCLUSIONS. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING COMPANY WILL ENDEAVOR TO MAIL TOWN OF TIBURON 1505 TIBURON BOULEVARD *30 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, TIBURON, CA 94920 BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE COMPANY, ITS AGENTS OR REPRESENTATIVES. *EXCEPT 10 DAYS FOR NON-PAYMENT AUTHORIZED REP ENT Endorsement. No. 3 ADDITIONAL INSURED - DESIGNATED PERSON OR ORGANIZATION IT IS AGREED THAT THE FOLLOWING ARE ADDED AS ADDITIONAL INSURED (S) HEREUNDER BUT ONLY AS RESPECTS LIABILITY ARISING OUT OF THE OPERATIONS OF THE NAMED INSURED, AND FURTHER PROVIDED THAT THE INCLUSION OF SUCH ADDITIONAL INSURED SHALL NOT SERVE TO INCREASE THE COMPANY'S LIMIT OF LIABILITY AS SPECIFIED IN THE DECLARATIONS OF THE POLICY. SCHEDULE NAMED INSURED: MARIN ENERGY AUTHORITY 3501 CIVIC CENTER DRIVE, #308 SAN RAFAEL, CA 94903 NAME OF PERSON OR ORGANIZATION/CERTIFICATE HOLDER: TOWN OF TIBURON 1505 TIBURON BOULEVARD TIBURON, CA 94920 CERTIFICATE HOLDER SHALL BE NAMED ADDITIONAL INSURED FOR GENERAL LIABILITY AS RESPECTS TO THE OPERATIONS OF THE NAMED INSURED. PER CERTIFICATES OF INSURANCE APPROVED BY THE COMPANY, AND ON FILE WITH THE COMPANY EFFECTIVE DATE OF THIS ENDORSEMENT: 01/28/10 ATTACHED TO AND FORMING APART OF POLICY NO.: C010407/002 All other terms and conditions remain unchanged. Insurer: ALLIED WORLD NATIONAL ASSURANCE CO. Special Liability Insurance Program (SLIP) Effective September 29, 2009 to September 29, 2010 DATE ISSUED: 2/23/10