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20-065 West Valley Community Services, Community Development Block Grant Program City Non-profit Capital Housing ProjectHeather 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-Vista Village
Final Audit Report 2020-06-24
Created:2020-06-12
By:Abby Ayende (AbigailA@cupertino.org)
Status:Signed
Transaction ID:CBJCHBCAABAAcTS7UqGJc9840RcJUgxCDwurHcl8czTT
"WVCS-Vista Village" History
Document created by Abby Ayende (AbigailA@cupertino.org)
2020-06-12 - 3:55:03 PM GMT- IP address: 108.204.1.114
Document emailed to Araceli Alejandre (aracelia@cupertino.org) for approval
2020-06-12 - 3:56:30 PM GMT
Document approved by Araceli Alejandre (aracelia@cupertino.org)
Approval Date: 2020-06-16 - 5:59:30 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 - 5:59:34 PM GMT
Email viewed by Heather M. Minner (heatherm@cupertino.org)
2020-06-20 - 11:06:55 PM GMT- IP address: 45.41.142.241
Document e-signed by Heather M. Minner (heatherm@cupertino.org)
Signature Date: 2020-06-20 - 11:07:27 PM GMT - Time Source: server- IP address: 52.39.49.65
Document emailed to Benjamin Fu (benjaminf@cupertino.org) for signature
2020-06-20 - 11:07:31 PM GMT
Email viewed by Benjamin Fu (benjaminf@cupertino.org)
2020-06-24 - 5:15:22 PM GMT- IP address: 104.47.46.254
Document e-signed by Benjamin Fu (benjaminf@cupertino.org)
Signature Date: 2020-06-24 - 5:15:31 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 - 5:15:34 PM GMT
Email viewed by Kirsten Squarcia 6/24/20 (kirstens@cupertino.org)
2020-06-24 - 6:40:39 PM GMT- IP address: 104.47.45.254
Document e-signed by Kirsten Squarcia 6/24/20 (kirstens@cupertino.org)
Signature Date: 2020-06-24 - 6:41:12 PM GMT - Time Source: server- IP address: 148.64.105.190
Signed document emailed to Araceli Alejandre (aracelia@cupertino.org), Kirsten Squarcia 6/24/20
(kirstens@cupertino.org), Abby Ayende (AbigailA@cupertino.org), cyrahc@cupertino.org, and 2 more
2020-06-24 - 6:41:12 PM GMT