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HomeMy WebLinkAboutSKMBT_C35112040408220CERTIFICATE OF LIABI _ LITY 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 C REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED 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). rKUUUCER Cossio Insurance Agency PO Box 188 Simpsonville, SC 29681 (864) 688-0121 INSURED Jubilee Jumps, Inc P. O. Box 1745 Windsor, CA 95492 Contact Name: Gene or Andrea Tevini hone 7078369200 TFax (A/C, No Ext)_ - I (A/C, No): E-Mail: jubileejumps@sbcglobal.net INSURER(S) AFFORDING COVERAGE INSURER A: Interstate Fire & Casualty CO (Chicago, IL) INSURER B: Lexington Insurance CO (BOSTON, MA) INSURER C: National Union Fire Insurance Company (S) INSURER D: DATE 2/8/2012 - 7075449046 { I NAIC # I INSURER E: COVERAGES CERTIFICATE NUMBER: ' 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 - - _ - - PE OF POLICY ADDL SUBR POLICY NUMBER T P LTR INSR WVD OLICY EFF POLICY EXP (MM/DD/YY) (MM/DDNY) LIMITS GENERAL LIABILITY FX] COMMERCIAL GENERAL LIABILITY Per Occurrence $1,000,000 TJ CLAIMS MADE X OCCUR General Aggregate Per Location $2,000,000 Prod ct d C I u s an ompleted Operations $2,000,000 A ~ X SFE1002432 1/28/2012 I 1/28/2013 Personal/Advertisers Liability $1,000,000 Employee Benefits Liability $1,000,000 Fire Legal Liability $300 000 GEN'L AGGREGATE LIMIT APPLIES PER , Medical Payments Excluded POLICY M PROJECT LOC ~ Self Insured Retention $2,500 AUTOMOBILE LIABILITY - ANY AUTO COMBINED SINGLE LIMIT (Ea accident) 1 $ 1,000,000 A ALL OWNED SCHEDULED AUTOS ❑ AUTOS SFE1002432 1/28/2012 1/28/2013 BODILY INJURY (Per Person) $ HIRED AUTOS X NON-OWNED AUTOS BODILY INJURY (Per accident) $ u PROPERTY DAMAGE $ (Per accident) UMBRELLA LIAB OCCUR Per Occurrence $1 000 000 B L EXCESS LIAB CLAIMS-MADE i 4574991 1/28/2012 1/28/2013 , , Aggregate $1,000,000 T DED RETENTION $ WORKERS COMPENSATION - - - AND EMPLOYERS' LIABILITY ANY PROPRIETOR/PARTNER ~ ER ITORY WC STATU- OTH- L LIMITS ER /EXECUTIVE ~ r /N OF - _ _ FICER/MEMBER EXCLUDED? r N/A ~ (Mandatory in NH) i If yes, describe under DESCRIPTION OF OPERATIONS below - - - Primary Accident & Health C Accident Medical I SRG 9112851 1/28/2012 1/28/2013 Accidental Death & Dismemberment $10,000 Aggregate applies to AD &D only $100 000 , Deductible None DESCRIPTION OF OPERATIONS /LOCATIONS /VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more ace is required) Party Equipment Rentals 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~~ 2 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE 1505 Tow Tiburon Blvd. (EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Tiburon, CA 94920 TOWN CLERK (ACCORDANCE WITH THE POLICY PROVISIONS. TOWN OF TIBURON ` (AUTHORIZED REPRESENTATIVE ACORD 25 (2010/05) The ACORD name and logo are registered marks of ACORD ©1988-2010 ACORD CORPORATION. All rights reserved. J