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DocuSign Envelope ID: D7EF525D-DBF6-4AO6-BOA8-1570CBCFE8C4
<br />AC"RCY CERTIFICATE OF LIABILITY INSURANCE DATE(MMlDD/YYYY)
<br />Ilr� t 7/13/21
<br />THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS
<br />CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
<br />BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED
<br />REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER.
<br />IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must have ADDITIONAL INSURED provisions or be endorsed.
<br />If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on
<br />this certificate does not confer rights to the certificate holder in lieu of such endorsement(s).
<br />PRODUCER CONTACT
<br />Edgewood Partners Insurance Center PHOONE Carley Resnik FAx
<br />P O. Box 2110 (AIC, No, Ext): (91 6)352-0492 lA/c, No): (915)583 7813
<br />Rancho Cordova CA 95670 aDgRLSS: cane .resnik@epicbrokers.com
<br />INSURERS AFFORDING COVERAGE NAIC#
<br />License#: OB29370 INSURER A: BETA Healthcare Group 99900
<br />INSURED AXISCOMM INSURERB: Federal Insurance Company 20281
<br />Axis Community Health, Inc
<br />5925 West Las Positas Blvd Suite 100 INSURERC: Federal Insurance Company 20281
<br />Pleasanton CA 94588 INSURER D:
<br />INSURER E:
<br />INSURER F :
<br />COVERAGES CERTIFICATE NUMBER: 1351474548 REVISION NUMBER:
<br />THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
<br />INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
<br />CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,
<br />EXCLUSIONS AND CONDITIONS OF SUCH POLICIES LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS
<br />INSR I TYPE OF INSURANCE ADDL SUBR POLICY EFF POLICY EXP
<br />LTR POLICYNUMBER MMIDDIYYYY] IMMIDD?VYYYI LIMITS
<br />A X COMMERCIAL GENERAL LIABILITY
<br />HCL231064
<br />7/1/2023
<br />7/1/2024 EACH OCCURRENCE $4.000.000
<br />CLAIMS -MADE IJ OCCUR
<br />DAMAGE W RENTED '
<br />PRldy{I, SESEa 500.000
<br />_$
<br />MED EXP (Anyone person) $ 5.000
<br />PERSONAL & ADV INJURY I $ 5.000.000
<br />I
<br />GEN'L AGGREGATE LIMIT APPLIES PER:
<br />GENERAL AGGREGATE $ 5,000,000
<br />X POLICY LOC
<br />PRODUCTS - COMP/OP AGG `$ Included
<br />OTHER:
<br />$
<br />B AUTOMOBILE LIABILITY
<br />73609833
<br />7/1/2023
<br />7/1/2024
<br />CO eB EDMSINGLE LIMIT
<br />$ 1,000,000
<br />ANY AUTO
<br />BODILY INJURY (Per (Per person
<br />$$
<br />OWNED SCHEDULED
<br />L J AUTOS ONLY AUTOS
<br />$
<br />BODILY INJURY (Per accident)
<br />PROPERTY QAMAGE
<br />XHIRED X NON -OWNED
<br />. AUTOS ONLY AUTOS ONLY
<br />.(Par..__,
<br />$
<br />UMBRELLALIAB OCCUR EACH OCCURRENCE
<br />$
<br />C� EXCESS LIAB CLAIMS -MADE AGGREGATE
<br />-
<br />$
<br />$
<br />I.
<br />DED RETENTION $
<br />A WORKERS COMPENSATION WC231064 7/1/2023 7/1/2024 X PER OTH-
<br />TER I
<br />AND EMPLOYERS' LIABILITY Y / N
<br />ANYPROPRIETOR/PARTNER/EXECUTIVE 2,000,000
<br />E L. EACH ACCIDENT $
<br />n NIA
<br />OFFICER/MEMBER EXCLUDED?
<br />(Mandatory in NH) E L. DISEASE- EA EMPLOYEEI $ 2,000,000
<br />If yes, describe under '
<br />. DESCRIPTION OF OPERATIONS below E L. DISEASE - POLICY LIMIT $ 2,000,000
<br />A Crime - Employee Theft HCL231064
<br />7/1/2023
<br />7/1/2024
<br />Limit / Deductible
<br />$400,000 / $2,000
<br />C Professional Liability Inc's A&M 82553413
<br />7/1/2023
<br />7/1/2024
<br />Each Claim /Ded
<br />$4,000,000 /$0
<br />Claims Made / Relro dale 5/1/77
<br />Policy Aggregate /Ded
<br />$5,000,000/ $0
<br />DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, maybe attached if more space is required)
<br />Excess Workers Compensation, Carrier: Safety National Casualty Corporation, NAIC #15105, Policy #SP4066651, Term: 07/01/23-07/01/24, Statutory Limits
<br />Excess of $1.000,000.
<br />Cyber Liability - Carrier: Beazley; Policy Number: W32E2A230201; Policy Term: 07/01/23-07/01/24, Limit of Liability: $2,000,000.
<br />Re: All Contracts/Written Agreements between the Certificate Holder and the Insured. Additional Insured: City of Pleasanton, its officials, employees, agents
<br />and volunteers When required by written contract, additional insured status with primary coverage and waiver of subrogation apply to General Liability and
<br />Workers' Compensation, all per the attached endorsements
<br />CERTIFICATE HOLDER CANCELLATION
<br />SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
<br />THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
<br />City of Pleasanton, its officials, employees, agents and ACCORDANCE WITH THE POLICY PROVISIONS.
<br />volunteers
<br />PO Box 520 AUTHORIZED REPRESENTATIVE
<br />Pleasanton CA 94566 --�
<br />©1988-2015 ACORD CORPORATION. All rights reserved.
<br />ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD
<br />
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