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HomeMy WebLinkAboutObrien_SLO_COI'Jr^ 0, DATE (MMIDDIYYYY) ACCW0 CERTIFICATE OF LIABILITY INSURANCE 06/15/2015 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 NAME, CONTACT Suzanne Kral, Agent CA Lic #0791269 A/c0NE Ext: 805-733-3591 A(AIXNo:805-733-0302 THOMCO ASSOCIATES INS SVCS ADMDRESS: suzannek insurance@yahoo.com 3875 CONSTELLATION RD INSURERS AFFORDING COVERAGE NAIC # STE A INSURERA:Security National Insurance Co 19879 LOMPOC CA 93436 INSURED INSURER B : CHRISTOPHER JON O'BRIEN DBA INSURERC: INSURERD:State Fund Compensation Insurance 35076 CHRISTOPHER O'BRIEN DESIGN & CONSTRUCTION INSURER E : PO BOX 12823 INSURER F: SAN LUIS OBISPO CA 93406 rOVFRAGFS 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 LTR TYPE OF INSURANCE ADDL UBR POLICY NUMBER MM POLICY EFF /DDfYYYY POLICY EXP MWDD/YYYY LIMITS A COMMERCIAL GENERAL LIABILITY CLAIMS -MADE © OCCUR X NA108568300 2015 01/12/2016 PER OTH- STATUTE I ER E.L. EACH ACCIDENT _ $ 11000,000 E.L. DISEASE - EA EMPLOYEE $ 1,000,000 E.L. DISEASE -POLICY LIMIT $ 1,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) Will be doing interior and exterior general contractor work and concrete work for the City of San Luis Obispo. City of San Luis Obispo, Public Works Department 919 Palm Street San Luis Obispo A Municipal Corporation CA 93401 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. REPRESENTATIVE / I©1988-2014 WCOIRD CORPORATION. All rights reserved. ACORD 25 (2014/01) The ACORD name and logo are regist4e4 marks of ACORD POLICY NUMBER NA108568300 COMMERCIAL GENERAL LIABILITY CG 2012 07 98 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - STATE OR POLITICAL SUBDIVISIONS - PERMITS This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE State Or Political Subdivision: CITY OF SAN LUIS OBISPO, A MUNICIPAL CORPORATION PUBLIC WORKS DEPT, 919 PALM ST SAN LUIS OBISPO CA 93401 (If no entry appears above, information required to complete this endorsement will be shown in the Declarations as applicable to this endorsement.) Section II — Who Is An Insured is amended to include as an insured any state or political subdivi- sion shown in the Schedule, subject to the following provisions: 1. This insurance applies only with respect to oper- ations performed by you or on your behalf for which the state or political subdivision has issued a permit. 2. This insurance does not apply to: a. 'Bodily injury," "property damage" or "person- al and advertising injury" arising out of opera- tions performed for the state or municipality; or b. 'Bodily injury" or "property damage" included within the "products -completed operations hazard". CG 2012 07 98 Copyright, Insurance Services Office, Inc., 1997 Page 1 of 1 0