Loading...
HomeMy WebLinkAboutADM25-0014 INSURANCEANY PROPRIETOR/PARTNER/EXECUTIVEOFFICER/MEMBER EXCLUDED? INSR ADDL SUBRLTRINSD WVD CONTACTNAME:FAXPHONE(A/C, No):(A/C, No, Ext): E-MAILADDRESS: INSURER A : INSURED INSURER B : INSURER C : INSURER D : INSURER E : INSURER F : POLICY NUMBER POLICY EFF POLICY EXPTYPE OF INSURANCE LIMITS(MM/DD/YYYY) (MM/DD/YYYY) AUTOMOBILE LIABILITY UMBRELLA LIAB EXCESS LIAB WORKERS COMPENSATIONAND EMPLOYERS' LIABILITY DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) AUTHORIZED REPRESENTATIVE EACH OCCURRENCE $DAMAGE TO RENTEDCLAIMS-MADE OCCUR $PREMISES (Ea occurrence) MED EXP (Any one person) $ PERSONAL & ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER:GENERAL AGGREGATE $ PRO-POLICY LOC PRODUCTS - COMP/OP AGGJECT OTHER:$COMBINED SINGLE LIMIT $(Ea accident) ANY AUTO BODILY INJURY (Per person) $OWNED SCHEDULED BODILY INJURY (Per accident) $AUTOS ONLY AUTOS HIRED NON-OWNED PROPERTY DAMAGE $AUTOS ONLY AUTOS ONLY (Per accident) $ OCCUR EACH OCCURRENCE CLAIMS-MADE AGGREGATE $ DED RETENTION $ PER OTH-STATUTE ER E.L. EACH ACCIDENT E.L. DISEASE - EA EMPLOYEE $If yes, describe under E.L. DISEASE - POLICY LIMITDESCRIPTION OF OPERATIONS below INSURER(S) AFFORDING COVERAGE NAIC # COMMERCIAL GENERAL LIABILITY Y / N N / A(Mandatory in NH) SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED INACCORDANCE WITH THE POLICY PROVISIONS. 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 DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY 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. THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIESBELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZEDREPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement onthis certificate does not confer rights to the certificate holder in lieu of such endorsement(s). COVERAGES CERTIFICATE NUMBER:REVISION NUMBER: CERTIFICATE HOLDER CANCELLATION © 1988-2015 ACORD CORPORATION. All rights reserved.ACORD 25 (2016/03) CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DD/YYYY) $ $ $ $ $ The ACORD name and logo are registered marks of ACORD (559) 584-3391 (559) 584-6262 23850 Soroptimist International of the Americas (CLUBS)1709 Spruce St Suite 101 Philadelphia, PA 19103 A 1,000,000 PHPK2709700-000 4/1/2025 4/1/2026 100,000 Prof Liability 5,000 Sexual Abuse 1,000,000 3,000,000 3,000,000 1,000,000A PHPK2709700-000 4/1/2025 4/1/2026 1,000,000A PHUB918888-000 4/1/2025 4/1/2026 1,000,000 10,000 Human Services General Liability Deluxe Endorsement applies as per form PI-GLD-HS with Special Events Endorsement per form PI-SE-001. Amendment of Liquor Liability Exclusion applies per form CG 21 51 04 13Event Name & Date: SOROINT-06 JHENDERSON PRODUCER Pacific Ag Insurance Agency Inc. 1715 N 11th AveHanford, CA 93230 JoannaA@pacificaginsurance.com Philadelphia Ins Comp. X X X X X XX X X X Justin Heskett & Jordan Koelewyn A Liquor Liability PHPK2709700-000 4/1/2025 4/1/2026 EACH OCCURENCE 1,000,000 FORM NUMBER: EFFECTIVE DATE: The ACORD name and logo are registered marks of ACORD ADDITIONAL REMARKS ADDITIONAL REMARKS SCHEDULE FORM TITLE: Page of THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, ACORD 101 (2008/01) AGENCY CUSTOMER ID: LOC #: AGENCY NAMED INSURED POLICY NUMBER CARRIER NAIC CODE © 2008 ACORD CORPORATION. All rights reserved. Pacific Ag Insurance Agency Inc. SOROINT-06 SEE PAGE 1 1 SEE PAGE 1 ACORD 25 Certificate of Liability Insurance 1 SEE P 1 Soroptimist International of the Americas (CLUBS)1709 Spruce St Suite 101Philadelphia, PA 19103 SEE PAGE 1 JHENDERSON 1 Endorsements Special Events Endorsement applies as follows: The rating for this endorsement applies to "bodily injury", "property damage", and "personal and advertising injury" arising out of all of your special events with the following exceptions unless scheduled in paragraph C. Schedule of Special Events below: The following special events shall be separately rated for additional premium: - Parades sponsored by the insured - Shooting activities - Fireworks - Carnivals and fairs with mechanical rides sponsored by the insured - Rock, Heavy Metal, Techno, Hip-Hop or Rap Concerts - Events including contact sports - Rodeos sponsored by the insured - Political Rallies - Any events with greater than 2,500 people at any one time (including otherwise acceptable events) - Any event with liquor provided by the insured if a license is required for such activity * Refer to Form CG 21 51 04 13 for Amendment of Liquor Liability Exclusion - Exception for Scheduled Premises or Activities, including: Fundraising events held by the insured