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INSR ADDL SUBR
<br />LTR INSR WVD
<br />DATE (MM/DD/YYYY)
<br />PRODUCER CONTACT
<br />NAME:
<br />FAXPHONE
<br />(A/C, No):(A/C, No, Ext):
<br />E-MAIL
<br />ADDRESS:
<br />INSURER A :
<br />INSURED INSURER B :
<br />INSURER C :
<br />INSURER D :
<br />INSURER E :
<br />INSURER F :
<br />POLICY NUMBER
<br />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/EXECUTIVE
<br />OFFICER/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 $GEN'L AGGREGATE LIMIT APPLIES PER:
<br />PRODUCTS - COMP/OP AGG $
<br />$
<br />PRO-
<br />OTHER:
<br />LOCJECT
<br />COMBINED SINGLE LIMIT
<br />$(Ea accident)
<br />BODILY INJURY (Per person)$ANY AUTO
<br />ALL OWNED SCHEDULED BODILY INJURY (Per accident)$AUTOS AUTOS
<br />HIRED AUTOS
<br />NON-OWNED PROPERTY DAMAGE $AUTOS (Per accident)
<br />$
<br />OCCUR EACH OCCURRENCE $
<br />CLAIMS-MADE AGGREGATE $
<br />DED RETENTION $$
<br />PER OTH-
<br />STATUTE ER
<br />E.L. EACH ACCIDENT $
<br />E.L. DISEASE - EA EMPLOYEE $
<br />If yes, describe under
<br />E.L. DISEASE - POLICY LIMIT $DESCRIPTION OF OPERATIONS below
<br />POLICY
<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 be endorsed. If SUBROGATION IS WAIVED, subject to
<br />the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the
<br />certificate holder in lieu of such endorsement(s).
<br />COVERAGES CERTIFICATE NUMBER:REVISION NUMBER:
<br />CERTIFICATE HOLDER CANCELLATION
<br />© 1988-2014 ACORD CORPORATION. All rights reserved.
<br />The ACORD name and logo are registered marks of ACORDACORD 25 (2014/01)
<br />ACORDTM CERTIFICATE OF LIABILITY INSURANCE 7/07/2016
<br />Dealey, Renton & Associates
<br />P. O. Box 12675
<br />Oakland, CA 94604-2675
<br />510 465-3090
<br />Nancy Ferrick
<br />510 465-3090 510 452-2193
<br />nferrick@dealeyrenton.com
<br />Sandis Civil Engineers
<br />Surveyors Planners
<br />3007 Douglas Blvd, Suite 105
<br />Roseville, CA 95661
<br />Travelers Indemnity Co. of Conn
<br />Travelers Property Casualty Co
<br />XL Specialty Insurance Co.
<br />25682
<br />25674
<br />37885
<br />A X
<br />X
<br />X
<br />X X 6807C80537A 03/03/2016 03/03/2017 1,000,000
<br />1,000,000
<br />10,000
<br />1,000,000
<br />2,000,000
<br />2,000,000
<br />B
<br />X
<br />X X
<br />X X BA7C810981 03/03/2016 03/03/2017 1,000,000
<br />B
<br />N
<br />X UB4027T041 03/03/2016 03/03/2017 X
<br />1,000,000
<br />1,000,000
<br />1,000,000
<br />C Professional
<br />Liability
<br />DPR9801771 03/03/2016 03/03/2017 $1,000,000 per Claim
<br />$1,000,000 Annl Aggr.
<br />General Liability Policy excludes claims arising out of the performance of professional services.
<br />30 Days Notice of Cancellation (10 Days for Non-Payment of Premium).
<br />Ref: Master On-call Surveying Services. The City of Redwood City, its officers, agents, employees and
<br />volunteers are included as Additional Insured for General and Automobile Liability. Insurance is primary
<br />and non-contributory per policy form. A Waiver of Subrogation applies to Workers' Compensation.
<br />City of Redwood City
<br />Community Development Department
<br />1017 Middlefield Road
<br />Redwood City, CA 94063
<br />1 of 1
<br />#S1753124/M1625950
<br />SANDICIVIClient#: 351
<br />NMF
<br />6.1.E. - Page 17
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