Certificate of Insurance - Charities Housing Development CorpA� 4/1/2016 ® CERTIFICATE OF LIABILITY INSURANCE DADDIYYYY)
016
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 endorsements .
CONTACT
PRODUCER NAME:
Arthur J. Gallagher & Co. PHONE I FAX
Insurance Brokers of CA, Inc. LIC #0726293 E-M "�' "`)
E-MAI L
1255 Battery Street, Suite 450 ADDR= - — -
San Francisco CA 94111 INSURERS) AFFORDING COVERAGE NAIC #
_ INSURER A: Philadelphia Indemnity Insurance Co 18058
INSURED INSURER B:Cypress Insurance Company (CA) 10855
- --- —� - —
Charities Housing Development Corp. of _INSURER c:
Santa Clara County, attn: Dan Wu
1400 Parkmoor Ave # 190 INSURER D
San Jose CA 95126 INSURER E
INSURER F :
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IrV VLRAVLJ VL..� •• vri.�,.v.�.v....�. ------- -------
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 El(P LIMITS
LTR INSD WVD POLICY NUMBER MIDDIYYYY MM/DD/YYYY
A
X
COMMERCIAL GENERAL LIABILITY
PHPK1468983
4/1l2016
4/1/2017
EACH OCCURRENCE
$1,000,000
PREMISES Ea occurrence
$1,000,000
CLAIMS -MADE OCCUR
MED EXP (Any one person)
$15,000
Ded/ReC $0
PERSONAL & ADV INJURY
$1,000,000
GEN'L AGGREGATE LIMIT APPLIES PER:
GENERAL AGGREGATE
$2,000,000
PRODUCTS - COMP/OP AGG
$2,000,000
POLICYF71 PRO LOC
JECT
$
OTHER:
A
AUTOMOBILE LIABILITY
PHPK1468983 4!1/2016
411/2017
Ea accident)$1,000,000
BODILY INJURY (Per person)
$
ANY AUTO
BODILY INJURY (Per accident)
E
ALL pSCHEDULED
AUTOSS
AMAGE
(Per accident)-
$
$
NON -OWNED
X HIRED AUTOS X AUTOS
A
X
UMBRELLA LIAB
X
OCCUR
PHUB534043 1 4/112016
4/1/2017
EACH OCCURRENCE
$8,000,000
AGGREGATE
$8,000,000
EXCESS LIAB
CLAIMS -MADE
DED X RETENTION $10,000
$
B
',WORKERS COMPENSATION
CHWC710415 4/1/2016
4/112017
X STATUTE ERH
AND EMPLOYERS' LIABILITY Y / N
ANY PROPRIETOR/PARTNER/EXECUTIVE
E.L. EACH ACCIDENT
$1,000,000
E.L. DISEASE - EA EMPLOYE
$1,000,000
OFFICER/MEMBER EXCLUDED? ❑
(Mandatory in NH)
N /A
i
E.L. DISEASE - POLICY LIMIT
$1,000,000
If yes, describe under
DESCRIPTION OF OPERATIONS below
A
Commercial Crime
PHPK1468983 4/1l2016
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 mare space Is required)
Included as Additional Insured as respects General Liability per attached CG2018 policy endorsement.
Named Insured Includes: Campbell Senior Homes LLC
RE: 2011 Pollard Road, Campbell, CA 95008.
City of Campbell is named as Additional Insured.
rroTICIr ATr Uni nrD 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 REPRESENTATIVE
r
ra 0.
WJ 1ytSS-L1U14 AL UKU UUKVVKAI IVIV. All rlgntb rtr56rV6U
ACORD 25 (2014101) The ACORD name and logo are registered marks of ACORD
/
ACORO® CERTIFICATE OF LIABILITY INSURANCE
`� .
DATE (MMIDD/YYYY)
1 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 endorsements .
PRODUCER
Arthur J. Gallagher & CO.
Insurance Brokers of CA, Inc. LIC #0726293
1255 Battery Street, Suite 450
CONTACT
NAME:
PHONE FAX
NO);-
- - - - —
ADDRESS:
_
INSURER(S) AFFORDING COVERAGE NAIC #
San Francisco CA 94111
_ _
INSURER A:Philadelphia Indemnity Insurance Co 1_8058
_
INSURED
INSURER B:Cypress Insurance Company (CA) 10855
INSURER C :
Charities Housing Development Corp. of
Santa Clara County, attn: Dan Wu
1400 Parkmoor Ave # 190
--- — --
INSURER D :
San Jose CA 95126
INSURER E
INSURER F :
COVFRAGFS CFRTIFICATF NIIMRFR- 1092857855 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.
ILTR
TYPE OF INSURANCE
INSD
I WVD
POLICY NUMBER
POLICY EFF
MMIDD/YYYY
POLICY EXP
MMIDDNYYY
LIMITS
A
X
COMMERCIAL GENERAL LIABILITY
PHPK1468983
4/1/2016
4/1/2017
EACH OCCURRENCE
$1,000,000
CLAIMS -MADE X� OCCUR
DAMAGE TENTED
PREMISES Ea occurrence
$1,000,000
MED EXP (Any one person)
E 15,000
Ded/Ret: $0
PERSONAL & ADV INJURY
$1,000,000
GEN'L
AGGREGATE LIMIT APPLIES PER:
GENERAL AGGREGATE
$2,000,000
POLICY 0PRO �
JECT LOC
PRODUCTS - COMP/OP AGG
f 2,000,000
_
OTHER:
A
AUTOMOBILE LIABILITY
PHPK1468983
4/1/2016
4/1/2017
Ea accident
s1,000,000
BODILY INJURY (Per person)
E
ANY AUTO
ALL OWNED SCHEDULED
AUTOS
BODILY INJURY (Per accident)
E
X HIRED AUTOS X NON -OWNED
AUTOS
3DAMAGE
PROPER
Per accident
L
$
A
X
UMBRELLA LIAB
X
OCCUR
PHUB534043
4/1/2016
4/1/2017
EACH OCCURRENCE
$8,000,000
AGGREGATE
$8,000,000
EXCESS LIAB
CLAIMS -MADE
DIED I X i RETENTION b 10,000
E
B
WORKERS COMPENSATION
AND EMPLOYERS' LIABILITY IN
ANY PROPRIETOR/PARTNER/EXECUIIVE Y❑
CHWC710415
4/1/2016
4/1/2017
H
X STATUTE ER
—
E.L. EACH ACCIDENT
E1,000,000
OF EXCLUDED?
(Mandatory in NH)
NIA
E.L. DISEASE - EA EMPLOYE
$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
IEmpi Dishonesty 1,000,000
Forgery/Alteration 250,000
I
DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached it 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: 88 Llewellyn Ave., 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 REPRESENTATIVE
C1'4111qn14C_f -)
® 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
Arthur J. Gallagher & Co. Insurance Brokers of CA., Inc.
1255 Battery Street #450
San Francisco, CA 94111
390 2 AB 0.917
I�'��I'III'�II"I.�I"�"'IIIIIIII�IIIIIIIIIII'lll�"��I�I�II�II�
CITY OF CAMPBELL
COMMUNITY DEVELOPMENT DEPARTMENT
70 N 1 ST ST UPPR C-390
CAMPBELL, CA 95008-1423