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INSR ADDLSUBRLTRINSR WVD
<br />DATE (MM/DD/YYYY)
<br />PRODUCER CONTACTNAME:
<br />FAXPHONE(A/C, No):(A/C, No, Ext):
<br />E-MAILADDRESS:
<br />INSURER A :
<br />INSURED INSURER B :
<br />INSURER C :
<br />INSURER D :
<br />INSURER E :
<br />INSURER F :
<br />POLICY NUMBER POLICY EFF POLICY EXPTYPE OF INSURANCE LIMITS(MM/DD/YYYY) (MM/DD/YYYY)
<br />COMMERCIAL GENERAL LIABILITY
<br />AUTOMOBILE LIABILITY
<br />UMBRELLA LIAB
<br />EXCESS LIAB
<br />WORKERS COMPENSATION
<br />AND EMPLOYERS' LIABILITY
<br />DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required)
<br />AUTHORIZED REPRESENTATIVE
<br />INSURER(S) AFFORDING COVERAGE NAIC #
<br />Y / N
<br />N / A
<br />(Mandatory in NH)
<br />ANY PROPRIETOR/PARTNER/EXECUTIVEOFFICER/MEMBER EXCLUDED?
<br />EACH OCCURRENCE $
<br />DAMAGE TO RENTED $PREMISES (Ea occurrence)CLAIMS-MADE OCCUR
<br />MED EXP (Any one person) $
<br />PERSONAL & ADV INJURY $
<br />GENERAL AGGREGATE $
<br />GEN'L AGGREGATE LIMIT APPLIES PER:
<br />PRODUCTS - COMP/OP AGG $
<br />$
<br />PRO-
<br />OTHER:
<br />LOCJECT
<br />COMBINED SINGLE LIMIT $(Ea accident)
<br />BODILY INJURY (Per person) $ANY AUTO
<br />OWNED SCHEDULED BODILY INJURY (Per accident) $AUTOS ONLY AUTOS
<br />AUTOS ONLYHIRED PROPERTY DAMAGE $AUTOS ONLY (Per accident)
<br />$
<br />OCCUR EACH OCCURRENCE $
<br />CLAIMS-MADE AGGREGATE $
<br />DED RETENTION $
<br />$
<br />PER OTH-STATUTE ER
<br />E.L. EACH ACCIDENT $
<br />E.L. DISEASE - EA EMPLOYEE $
<br />If yes, describe under E.L. DISEASE - POLICY LIMIT $DESCRIPTION OF OPERATIONS below
<br />POLICY
<br />NON-OWNED
<br />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 />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 />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 any rights to the certificate holder in lieu of such endorsement(s).
<br />COVERAGES CERTIFICATE NUMBER: REVISION NUMBER:
<br />CERTIFICATE HOLDER CANCELLATION
<br />© 1988-2015 ACORD CORPORATION. All rights reserved.
<br />The ACORD name and logo are registered marks of ACORDACORD 25 (2016/03)
<br />ACORDTM CERTIFICATE OF LIABILITY INSURANCE
<br />Nautilus Insurance Company
<br />Great Divide Insurance Company
<br />Lloyd's Syndicate 3623
<br />Houston Casualty Company
<br />MSIG Specialty Insurance USA, Inc.
<br />1/05/2026
<br />USI Southwest
<br />9811 Katy Freeway, Suite 500
<br />Houston, TX 77024
<br />855 874-1450
<br />Evan Reeves
<br />713-490-4600
<br />cert.service@usi.com
<br />FCS International, Inc
<br />250 Commerce Suite 210
<br />Irvine, CA 92602
<br />17370
<br />25224
<br />NONAIC
<br />42374
<br />34886
<br />AX
<br />X
<br />X BI/PD Ded:10000
<br />X
<br />ECP204889610 01/01/2026 01/01/2027 1,000,000
<br />100,000
<br />5,000
<br />1,000,000
<br />2,000,000
<br />2,000,000
<br />E
<br />X Deductible
<br />XX
<br />5,000
<br />HNO100099400 01/01/2026 01/01/2027 1,000,000
<br />Deductible 5,000
<br />A
<br />X
<br />X FFX204889710 01/01/2026 01/01/2027 5,000,000
<br />5,000,000
<br />B
<br />N
<br />WCA204889510 01/01/2026 01/01/2027 X
<br />1,000,000
<br />1,000,000
<br />1,000,000
<br />C
<br />D
<br />Cyber
<br />E&O Liability
<br />D316F7260501
<br />HCC2626391
<br />01/01/2026
<br />01/01/2026
<br />01/01/2027
<br />01/01/2027
<br />$2M agg ; $5k ded
<br />$2M ea claim/$4M agg
<br />$100k ded ea claim
<br />Re: All Operations
<br />City of Pleasanton, its officers, employees and agents are Additional Insureds with respect to General and
<br />Auto Liability per the attached endorsements as required by written contract. Insurance is Primary and Non
<br />Contributory. Waiver of Subrogation applies to General Liability and Workers' Compensation. 30 Days Notice
<br />of Cancellation with 10 Days Notice for Non-Payment of Premium in accordance with the policy provisions.
<br />City of Pleasanton
<br />P.O. Box 520
<br />Pleasanton, CA 94566
<br />1 of 1#S52460956/M52460519
<br />FCSINTClient#: 2100128
<br />LXAHA
<br />Docusign Envelope ID: 2B24D79F-D07B-8023-831C-EAC48253B99E
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