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SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
<br />THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
<br />ACCORDANCE WITH THE POLICY PROVISIONS.
<br />INSURER(S) AFFORDING COVERAGE
<br />INSURER F :
<br />INSURER E :
<br />INSURER D :
<br />INSURER C :
<br />INSURER B :
<br />INSURER A :
<br />NAIC #
<br />NAME:CONTACT
<br />(A/C, No):FAX
<br />E-MAILADDRESS:
<br />PRODUCER
<br />(A/C, No, Ext):PHONE
<br />INSURED
<br />REVISION NUMBER:CERTIFICATE NUMBER:COVERAGES
<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 />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 />OTHER:
<br />(Per accident)
<br />(Ea accident)
<br />$
<br />$
<br />N / A
<br />SUBR
<br />WVD
<br />ADDL
<br />INSD
<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 />$
<br />$
<br />$
<br />$PROPERTY DAMAGE
<br />BODILY INJURY (Per accident)
<br />BODILY INJURY (Per person)
<br />COMBINED SINGLE LIMIT
<br />AUTOS ONLY
<br />AUTOSAUTOS ONLY
<br />NON-OWNED
<br />SCHEDULEDOWNED
<br />ANY AUTO
<br />AUTOMOBILE LIABILITY
<br />Y / N
<br />WORKERS COMPENSATION
<br />AND EMPLOYERS' LIABILITY
<br />OFFICER/MEMBER EXCLUDED?
<br />(Mandatory in NH)
<br />DESCRIPTION OF OPERATIONS below
<br />If yes, describe under
<br />ANY PROPRIETOR/PARTNER/EXECUTIVE
<br />$
<br />$
<br />$
<br />E.L. DISEASE - POLICY LIMIT
<br />E.L. DISEASE - EA EMPLOYEE
<br />E.L. EACH ACCIDENT
<br />EROTH-STATUTEPER
<br />LIMITS(MM/DD/YYYY)POLICY EXP(MM/DD/YYYY)POLICY EFFPOLICY NUMBERTYPE OF INSURANCELTRINSR
<br />DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required)
<br />EXCESS LIAB
<br />UMBRELLA LIAB $EACH OCCURRENCE
<br />$AGGREGATE
<br />$
<br />OCCUR
<br />CLAIMS-MADE
<br />DED RETENTION $
<br />$PRODUCTS - COMP/OP AGG
<br />$GENERAL AGGREGATE
<br />$PERSONAL & ADV INJURY
<br />$MED EXP (Any one person)
<br />$EACH OCCURRENCE
<br />DAMAGE TO RENTED $PREMISES (Ea occurrence)
<br />COMMERCIAL GENERAL LIABILITY
<br />CLAIMS-MADE OCCUR
<br />GEN'L AGGREGATE LIMIT APPLIES PER:
<br />POLICY PRO-JECT LOC
<br />CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DD/YYYY)
<br />CANCELLATION
<br />AUTHORIZED REPRESENTATIVE
<br />ACORD 25 (2016/03)
<br />© 1988-2015 ACORD CORPORATION. All rights reserved.
<br />CERTIFICATE HOLDER
<br />The ACORD name and logo are registered marks of ACORD
<br />HIRED
<br />AUTOS ONLY
<br />12/30/2025
<br />Pinnacle Brokers -Northern California
<br />2125 Ygnacio Valley Road,Suite 200
<br />Walnut Creek CA 94598
<br />925-952-8680 925-952-8681
<br />certs@pinnbrokers.com
<br />License#:OM93299 National Interstate Insurance Company 32620
<br />BLACTIE-01 Insurance Company of the West 27847BlackTieTransportation,LLC
<br />7080 Commerce Drive
<br />Pleasanton CA 94588
<br />Millers Capital Insurance Company 14575
<br />1398506444
<br />A X 5,000,000
<br />X 100,000
<br />5,000
<br />5,000,000
<br />5,000,000
<br />X
<br />Y Y YPP573526001 5/1/2025 5/1/2026
<br />5,000,000
<br />SI Retention value 0
<br />A 5,000,000
<br />X
<br />YPP573526001 5/1/2025 5/1/2026
<br />A X 5,000,000
<br />X
<br />YEX573526001 5/1/2025 5/1/2026
<br />5,000,000
<br />X 0
<br />B X
<br />Y
<br />Y WPL216338818 7/1/2025 7/1/2026
<br />1,000,000
<br />1,000,000
<br />1,000,000
<br />A
<br />C
<br />Sexual Abuse or Molestation
<br />Excess Sexual Abuse/Molestation YPP573526001
<br />B0621PBLAC023925
<br />5/1/2025
<br />7/29/2025
<br />5/1/2026
<br />5/1/2026
<br />Per Claim/Agg
<br />Per Claim/Agg
<br />$1M/$1M
<br />$1M/$3M
<br />City of Pleasanton,its officers,officials,employees,and agents are afforded additional insured status as per the embedded coverages found in the coverage
<br />forms when required by written contract,agreement or permit but only as respects to the liability of the insured,pursuant to the terms,conditions,limitations and
<br />exclusions of the listed policies.Coverage for the General Liability is on a Primary &Non-Contributory basis.Waiver of Subrogation applies in favor of the
<br />additional insureds.The Workers Compensation policy includes a Waiver of Subrogation in favor of the Additional insureds.Notice of Cancellation will be issued
<br />to the First Named Insured only as per the policy terms and conditions.
<br />City of Pleasanton
<br />400 Old Bernal
<br />Pleasanton CA 94566
<br />Docusign Envelope ID: 2C9A65BB-21B7-4E3B-A5B5-F713B3B31D24Docusign Envelope ID: 8D82D9D4-0EDC-4063-A4B1-305FA902188EDocusign Envelope ID: 0D1BA1AB-EE6C-4FC0-8B30-14755F8114EE
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