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HomeMy WebLinkAbout2011-12 California Youth SoccerPage 1 of 1 Diane Crane lacopi From: stibich@aol.com Sent: Friday, August 19, 2011 3:04 PM To: Diane Crane lacopi; Joel Brewer Subject: Fwd: INSURANCE CERTIFICATE; TOWN OF TIBURON Attachments: Certificate. PD F; 1_CG20261185.pdf Hi Diane and Joel, This is a 3rd Certificate of Insurance for us. (We have 3 different policies so you should have all 3 now). Thanks, Kim Stibich -----Original Message----- From: California Youth Soccer <dalvarez@CYSANorth.org> To: Tiburon Peninsula Soccer club <STIBICH@AOL.COM> Sent: Fri, Aug 19, 2011 2:59 pm Subject: INSURANCE CERTIFICATE; TOWN OF TIBURON INSURANCE CERTIFICATE; TOWN OF TIBURON 8/22/2011 AC4ORtf CERTIFICATE OF LIABILITY INSURANCE i ° DATE(MM/DD/YYYY) ft. 8/19/2011 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 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 endorsement(s). PRODUCER CONrA= NAME: Bollinger Insurance PHONE FAX 101 JFK Parkway A/C No Ext : 973-467-800c; A/C, No):97'1-921 -2876 Short Hills NJ 07078 E-MAIL ADDRESS: PRODUCER CUSTOMER ID INSURER(S) AFFORDING COVERAGE NAIC # INSURED INSURER A:Philadelphia Indemnity Ins Cc 18058 California Youth Soccer 1040 Ser entine L Suite 201 INSURER B:Chaltti5 Insurance 35351 p , Pleasanton CA 94566 INSURER C INSURER D : INSURER E : INSURER F : COVERAGES CERTIFICATE NUMBER: 106120256n REVISION NIIMRFR- 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 ADDL ISUBR I POLICY NUMBER POLICY EFF MM/DD/YYYY POLICY EXP MM/DD/YYYY LIMITS A GENERAL LIABILITY PHPK754532 9/1/2011 9/1/2012 EACH OCCURRENCE $1,000,000 OMMERCIAL GENERAL LIABILITY C DAMA E PREMISES T RENTED Ea occurrence $1, 000, 000 1 CLAIMS-MADE ~ OCCUR : : `c MED EXP (Anyone person) $5, 000 X Part Lia I , 1 PERSONAL & ADV INJURY $1,000,000 1 GENERAL AGGREGATE $5,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP/OP AGG $2,000,000 POLICY PRO LOC $ A AUT OMOBILE LIABILITY PKPK754532 9/1/2011 9/1/2012 COMBINED SINGLE LIMIT 000 $1 000 ANY AUTO (Ea accident) , , ALL OWNED AUTOS BODILY INJURY (Per person) $ SCHEDULED A TO BODILY INJURY (Per accident) $ U S PROPERTY DAMAGE $ X HIRED AUTOS (Per accident) X NON-OWNED AUTOS $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DEDUCTIBLE $ RETENTION $ $ WORKERS COMPENSATION WC STATU- OTH- AND EMPLOYERS' LIABILITY TORY LIMITS ER Y / N ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? ❑ N/A E.L. EACH ACCIDENT $ (Mandatory In NH) E.L. DISEASE - EA EMPLOYE $ If yes, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT $ B Accident Coverage SRG9125874 9/1/2011 9/1/2012 Medical Max: $300,000 Full Excess Ded: $250/Claim DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space Is required) All 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 CERTIFICATES IS VALID ONLY FOR CYSA NORTH SANCTIONED EVENTS/ACTIVITIES. Certificate is issued on behalf of See Attached... CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. TOWN OF TIBURON 1505 TIBURON BLVD. TIBURON CA 94920 AUTHORIZED REPRESENTATIVE (~Qr ©1988-2009 ACORD CORPORATION. All rights reserved. ACORD 25 (2009/09) The ACORD name and logo are registered marks of ACORD AGENCY CUSTOMER ID: LOC .ACV ADDITIONAL REMARKS SCHEDULE Page 1 of 1 AGENCY Bollinger Insurance NAMED INSURED California Youth Soccer 1040 S ti 201 L S it POLICY NUMBER erpen ne , u e Pleasanton CA 94566 CARRIER NAIC CODE EFFECTIVE DATE: ADDITIONAL REMARKS I THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, I FORM NUMBER: 25 FORM TITLE: CERTIFICATE OF LIABILITY INSURANCE IBURON PENINSULA SOCCER CLUB roup Code: 5-06 ACORD 101 (2008/01) © 2008 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD POLICY NUMBER:PHPK754532 COMMERCIAL GENERAL LIABILITY THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - DESIGNATED PERSON OR ORGANIZATION This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART. SCHEDULE Name of Person or Organization: TOWN OF TIBURON 1505 TIBURON BLVD. TIBURON CA 94920 (If no entry appears above, information required to complete this endorsement will be shown in the Declarations as applicable to this endorsement.) WHO IS AN INSURED (Section II) is amended to include as an insured the person or organization shown in the Schedule as an insured but only with respect to liability arising out of your operations or premises owned by or rented to you. CG 20 26 11 85 Copyright, Insurance Services Office, Inc., 1984 Page 1 of 1