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ATTACHMENT "A" SAMPLE INSURANCE CERTIFICATE CERTIFICATE OF INSURANCE Producer: NAME AND ADDRESS OF INSURANCE AGENT Insured: NAME AND ADDRESS OF LICENSED CONTRACTOR ~ BE A LICENSED CONTRACTV A General Liability Commercial X Claims made X Occur. Owner's & Contractors pr Auto Liability Any Auto X All owned autos Scheduled autos Garage liability Excess Liability Other than Umbrella forrn Worker's Comp & Employer's Liability Current Date ISSUE DATE: This certificate is issued as a matter of information only and confers no rights upon the certificate holder. This certificate does not amend, extend or alter the coverage afforded by the policies below. COMPANIES AFFORDING COVERAGE Co. Letter "A" Aetna Casualty Co. Letter "B" Co. Letter "C" Co. Letter"D" Co. Letter "E" Limits Current Date $1,000,000 General Aggregate Products-Comp/Op Agg. Personal & Adv. Injury ...............~..~.~.~_?.~-~.~~.~:~.~~................................. $1,000,000 GENERAL LlABILILlTY, EACH OCCURENCE MUST BE $1,000,000 Fire Damage (any 1 fire) Medical Exp (any 1 person) Cornbined single lirn~~........................... $1,000,000 Current Date Current Date Bodily injuryjper1:iccident) ..".......""'" ........" "-Bõdily injury (per person) Property damage IF NEEDED Current Date Coverage 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 docurnent with respect to which this certificate rnay 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. Co. Type of Insurance Policy No. Effective Date Exp.Date Letter B c D Current Date Current Date Aggregate Current Date Statutory Limits Each accident Disease-policy limit Disease-each employee Other Description of Operations/LocationsNehicles/Specialltems: (Provide project address & name & description.) Add the following: The City of Redwood City, its council members, officers, boards, commissions, employees and Agents are named as additional primary insureds. Certificate Holder: City of Redwood City Engineering & Construction P.O. Box 391 Redwood City, CA 94064 Cancellation: It is understood and agreed that in the event of cancellation of the policy for any reason, including non-payment of premium, 30 days written notice will be sent to the certificate holder named on the left. Authorized Representati . SUBMIT ORIGINAL SIGNED CERTIFICATE 9/27/2005