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HomeMy WebLinkAboutSKMBT_C3511201041026012/23/2011 6:46:31 AM -0700 FAXCOM Total Pages: 5 PAGE 1 OF 5 Enterprise Fax To: From: cyberpd1 Fax: 415-435-2438 Phone: Phone: Date: Fax Number: Re: * Comments: 0 E C E ~ Y E -D JAN - 4 2012 TOWN CLERK TOWN OF TIBURON NOTICE: CONFIDENTIAL AND PRIVILEGED INFORMATION - This fax may contain confidential and privileged material for the sole use of the intended recipient(s). Any review, use, distribution, or disclosure by others is strictly prohibited. If you are not the intended recipient (or authorized to receive for the recipient), please contact the sender by telephone and destroy all copies of this correspondence. If you no longer wish to receive faxes from us, please contact the sender of this fax and we will remove your fax number from our list. Please allow us up to 10 business days to update our records. 12/23/2011 6:46:31 AM -0700 FAXCOM Commercial Lines - (973) 437-2300 Wells Fargo Insurance Services USA, Inc. 7 Giralda Farms, 2nd Floor Madison, NJ 07940-1027 To : Town Of Tiburon From: Marcia Samples (404-923-3800) Fax : 415-435-2438 Subject: Certificate Of Insurance on behalf of (Girl Scouts of Northern California ) PAGE 2 OF 5 Comments: This is your requested certificate of insurance. CID: NORTCALI, SID: 3694677 This certificate was sent to you using CyberSure, Wells Fargo Insurance Service's client portal. This message may contain confidential and/or privileged information. If you are not the addressee or authorized to receive this for the addressee, you must not use, copy, disclose, or take any action based on This message or any information herein. If you have received this message in error, please advise the sender immediately by reply fax and delete this message. Thank you for your coop eratt on. 12/23/2011 6:46:31 AM -0700 FAXCOM PAGE 3 OF 5 NO RTCAL 1 CERTIFICATE OF LIABILITY INSURANCE DATE(MIMIDONYYY) 1 12/23/2011 11 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(les) 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 CONTACT- NAME: Commercial Lines - (973) 437-2300 PHONE FAR A/C No Ext : A/C No : Wells Fargo Insurance Services USA, Inc. E-MAJL ADDRESS: 7 Giralda Farms, 2nd Floor IN AFFORDING COVERAGE NAIC 0 Madison, NJ 07940-1027 INSURER A: Travelers Indemnity Co. of Connecticut 25682 INSURED INSURER B : Girl Scouts of Northern California INSURER C 7700 Edgewater Drive, Suite 340 INSURER O: INSURER E : Oakland, CA 94621 0149 INSURER F : 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 POLICY NUMBER MM/DONYYY MM/DD/YYYY LIMITS A GENERAL LIABILITY 6608772L816 01/01/12 01101/13 EACH OCCURRENCE - $ 1,000,000 X COMMERCIAL GENERAL LIABILITY DAMAGE7UTTRI r- Li PREMISES Ea occurrence) $ 1,000.000 CLAIMS-MADE FX: ]OCCUR MED EXP (Any one person) $ 10,000 PERSONAL 4 ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 5.000.000 GEN`L AGGREGATE LIMIT APPLIES PER: - PRODUCTS - COMP/OP AGG $ 2,000.000 1 F~ POLICY PRO F LOC JECT $ AUT OMOBILE LIABILITY LIMIT (Ea accident) $ ANY AUTO BODILY INJURY (Per person) $ ALL OWNED AUTOS SCHEDULED AUTOS BODILY INJURY (Per accident) $ HIRED AUTOS NON OWNED AUTOS PROPERTY DAMAGE Per accident $ UMBRELLA LIAR H OCC EACH OCCURRENCE $ EXCESS LIAR CLAIMS-MADE AGGREGATE $ DED RETENTION $ $ WORKERS COMPENSATION WC STATU- OTH- AND EMPLOYERS' LIABILITY LIMIT YIN ANY PROPRIETOR/PARTNER/EXECUTIVE a OFFICERIMEMBER EXCLUD D? MIA E.L. EACH ACCIDENT $ E (Mandatory In NH) E.L. DISEASE - EA EMPLOYEE $ It yes, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT $ DESCRIPTION OF OPERATIONS I LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, If more space Is required) The Town Of Tiburon is named additional insured on the general liability policy per form CGD3660710 with respect to the use of its premises for Girl Scout activities of the insured Girl Scout Council. Insurance is primary and non-contributory per the wording on the policy. Insurance includes and endorsement providing the town, its agents, officials and employees, primary and non-contributory for claims, losses, etc. arising from the exercise of the permit. vcr~ ~ rrivr~ r c nvwcr< ~rl"1PIV CLLf+►1 IVIY Town Of Tiburon Attn: Joan 1505 Tiburon Blvd Tiburon, CA 94920 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 The ACORD name and logo are registered marks ofACORD © 1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25 (2010105) 12/23/2011 6:46:31 AM -0700 FAXCOM POLICY NUMBER: 66087721-816 PAGE 5 OF 5 COMMERCIAL GENERAL LIABILITY ISSUE DATE: 01/01/12 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY, IDENTIFICATION OF ADDITIONAL INSURED ENDORSEMENT This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL L.IABILJTY COVERAGE PART Nam of Petson or OrgarrizoMon SCHEDULE -Town Of Tiburon Attn: Joan 1505 Tiburon Blvd Tiburon, CA 94920 PROVISIONS Any pwson or organization shown in the Schedule above who aiualifies as an insured under SECTION Q -WHO IS AN INSURED, or under any amendment to that Section, is identified as an insiood for liability ooverage, but only with respect to liability arisiang out of your acts or omissions to which this insurance applies. CG 06 16 07 10 0 20 10 The Trsv lems Indemnity Cerny. 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