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20-066 West Valley Community Services, General Fund Human Services Grants Program City Non-Profit ContractHeather M. Minner Kirsten Squarcia 6/24/20 ANY PROPRIETOR/PARTNER/EXECUTIVEOFFICER/MEMBER EXCLUDED? INSR ADDL SUBRLTRINSDWVD PRODUCER 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 IN ACCORDANCE 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 POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE 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 on this 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 6/1/2020 (408) 792-5400 (408) 792-3670 18058 West Valley Community Services of Santa Clara County, Inc. 10104 Vista Drive Cupertino, CA 95014 16608 A 1,000,000 X PHPK2134952 6/1/2020 6/1/2021 100,000 5,000 1,000,000 3,000,000 1,000,000 SEXUAL ABUSE MO 1,000,000 1,000,000A PHPK2134952 6/1/2020 6/1/2021 2,000,000A PHUB722967 6/1/2020 6/1/2021 2,000,000 10,000 B WC201800007927 12/31/2019 12/31/2020 1,000,000 1,000,000 1,000,000 RE: Events under written contract City of Cupertino, Its Officials & Employees named as an additional insured per form CG 2026 04/13 attached. Primary wording applies. Blanket Work Comp waiver endorsement WC 04 03 06 attached- (Form CIR attached) City of Cupertino, Its Officials & Employees Attn: Recreation & Community Services/Facilities 10300 Torre Avenue Cupertino, CA 95014 WESTVAL-05 MARIAVELASQUEZ NFP Property & Casualty Services, Inc. 160 West Santa Clara Street Suite 575San Jose, CA 95113 Philadelphia Indemnity Insurance Company New York Marine And General Insurance Company X X X X X X X X 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. NFP Property & Casualty Services, Inc. WESTVAL-05 SEE PAGE 1 1 SEE PAGE 1 ACORD 25 Certificate of Liability Insurance 1 SEE P 1 West Valley Community Services of Santa Clara County, Inc.10104 Vista DriveCupertino, CA 95014 SEE PAGE 1 MARIAVELASQUEZ 1 CIR CONTRACTUAL INSURANCE REQUIREMENTS The attached Certificate of Insurance is provided as part of our service to our client, the Insured. If special endorsements have been provided, they also are indicated attached. You may find that these documents do not comply with all the terms and conditions of the underlying contract between the Certificate Holder and the Insured due to the insurance company’s insuring conditions, limitations, exclusions and other terms. If you have any questions, please contact the undersigned. NFP Property and Casualty Services, Inc. 160 West Santa Clara Street, Suite #575 CA License #0F15715 TELEPHONE: 408.792.5400 FAX: 408.792.3670 WVCS-Haven to Home Final Audit Report 2020-06-24 Created:2020-06-12 By:Abby Ayende (AbigailA@cupertino.org) Status:Signed Transaction ID:CBJCHBCAABAAgUuu0mESd71FUokmX95-VcJ-cRz5cdEy "WVCS-Haven to Home" History Document created by Abby Ayende (AbigailA@cupertino.org) 2020-06-12 - 4:01:23 PM GMT- IP address: 108.204.1.114 Document emailed to Araceli Alejandre (aracelia@cupertino.org) for approval 2020-06-12 - 4:02:49 PM GMT Document approved by Araceli Alejandre (aracelia@cupertino.org) Approval Date: 2020-06-16 - 6:03:06 PM GMT - Time Source: server- IP address: 24.23.184.82 Document emailed to Heather M. Minner (heatherm@cupertino.org) for signature 2020-06-16 - 6:03:10 PM GMT Email viewed by Heather M. Minner (heatherm@cupertino.org) 2020-06-20 - 11:06:06 PM GMT- IP address: 45.41.142.220 Document e-signed by Heather M. Minner (heatherm@cupertino.org) Signature Date: 2020-06-20 - 11:06:42 PM GMT - Time Source: server- IP address: 52.39.49.65 Document emailed to Benjamin Fu (benjaminf@cupertino.org) for signature 2020-06-20 - 11:06:45 PM GMT Email viewed by Benjamin Fu (benjaminf@cupertino.org) 2020-06-24 - 5:15:01 PM GMT- IP address: 104.47.46.254 Document e-signed by Benjamin Fu (benjaminf@cupertino.org) Signature Date: 2020-06-24 - 5:15:10 PM GMT - Time Source: server- IP address: 24.130.171.172 Document emailed to Kirsten Squarcia 6/24/20 (kirstens@cupertino.org) for signature 2020-06-24 - 5:15:15 PM GMT Email viewed by Kirsten Squarcia 6/24/20 (kirstens@cupertino.org) 2020-06-24 - 6:41:25 PM GMT- IP address: 104.47.46.254 Document e-signed by Kirsten Squarcia 6/24/20 (kirstens@cupertino.org) Signature Date: 2020-06-24 - 6:41:50 PM GMT - Time Source: server- IP address: 148.64.105.190 Signed document emailed to Araceli Alejandre (aracelia@cupertino.org), Heather M. Minner (heatherm@cupertino.org), Kirsten Squarcia 6/24/20 (kirstens@cupertino.org), Benjamin Fu (benjaminf@cupertino.org), and 2 more 2020-06-24 - 6:41:50 PM GMT