Certificate of Insurance - Charities Housing Development® DATE (MMIDD/YYYY)
CERTIFICATE OF LIABILITY INSURANCE 4/1/2016
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
Arthur J. Gallagher & Co.
Insurance Brokers of CA, Inc. LIC #0726293
1255 Battery Street, Suite 450
San Francisco CA 94111
INSURED
Charities Housing Development Corp. of
Santa Clara County, attn: Dan Wu
1400 Parkmoor Ave # 190
San Jose CA 95126
FAX
AFFORDING COVERAGE
demnitv Insurance Co
Insurance
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8058
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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 TYPE OF INSURANCE POLICY EFF POLICY EXP LIMITS
LTR D POLICY NUMBER MMIDDNYYY
A
X COMMERCIAL GENERAL LIABILITY PHPK1468983 4/1/2016
4/1/2017
EACH OCCURRENCE
$1,000,000
CLAIMS -MADE X❑ OCCUR
PREMISES Ea occurrence
$1,000,000
MED EXP (Any one person)
$15,000
Ded/Ret: $0
PERSONAL & ADV INJURY
$1,000,000
GENERAL AGGREGATE
$2,000,000
GEN'L AGGREGATE LIMIT APPLIES PER:
POLICY ❑ PECT 7 LOC
PRODUCTS - COMP/OP AGG
$2,000,000
$
OTHER:
A
AUTOMOBILE LIABILITY PHPK1468983
4/1/2016
4/1/2017
Ea accident
$1,000,000
BODILY INJURY (Per person)
$
ANY AUTO
ALL OWNED $UT€QULED
nANON-OaSWNED
BODILY INJURY (Per accident)
$
X HIRED AUTOS X AUTOS
Per accident
$
$
A
X UMBRELLA LIAB
X
OCCUR
PHUB534043
4/l/2016
4/1/2017
EACH OCCURRENCE
$8,000,000
AGGREGATE
$8,000,000
EXCESS LIAR
CLAIMS -MADE
DED I X I RETENTION $10,000
$
B
WORKERS COMPENSATION
AND EMPLOYERS' LIABILITY N
ANY PROPRIETOR/PARTNER/EXECU I IVE Y /❑
CHWC710415
4/1/2016
4/1/2017
X I STATUTE I EOH-
R
E.L. EACH ACCIDENT
$1,000,000
OFFICER/MEMBER EXCLUDED?
(Mandatory in NH)
NIA
E.L. DISEASE - EA EMPLOYEE
$1,000,000
E.L. DISEASE - POLICY LIMIT
$1,000,000
If yes, describe under
DESCRIPTION OF OPERATIONS below
A Commercial Crime
PHPK1468983
4/1/2016
4/1/2017
Empl Dishonesty 1,000,000
Forgery/Alteration 250,000
DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached If more space is required)
Included as Additional Insured as respects General Liability per attached CG2018 policy endorsement.
Named Insured Includes: Campbell Senior Homes LLC.
RE: 1120 Fairlands Ct, Campbell, CA 95008.
City of Campbell is named as Additional Insured.
CERTIFICATE HOLDER CANCELLATION
City of Campbell
Community Development Department
70 N. First Street
Campbell CA 95008
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 REPR�EENNTATIVE
�A'N11��G4vA �
m 1988-2014 ACORD CORPORATION. All rights reserved.
ACORD 25 (2014/01) The ACORD name and logo are registered marks of ACORD
POLICY NUMBER: PHPK1468983
COMMERCIAL GENERAL LIABILITY
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
ADDITIONAL INSURED -
MORTGAGEE, ASSIGNEE, OR RECEIVER
This endorsement modifies insurance provided under the following:
COMMERCIAL GENERAL LIABILITY COVERAGE PART
SCHEDULE
Name of Person or Organization: City of Campbell
Designation of Premises: Community Development Department
(If no entry appears above, information required to complete this endorsement will be shown in the Declarations
as applicable to this endorsement.)
1. WHO IS AN INSURED (Section II) is amended to include as an insured the person(s) or organization(s)
shown in the Schedule but only with respect to their liability as mortgagee, assignee, or receiver and arising
out of the ownership, maintenance, or use of the premises by you and shown in the Schedule.
2. This insurance does not apply to structural alterations, new construction and demolition operations performed
by or for that person or organization.
CG 20 18 11 85 Copyright, Insurance Services Office, Inc., 1984 Page 1 of 1