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17-160 C. Cruz Subsurface Locators, Inc., Locate and Mark Existing Utilities with the Proposed Work Area at the Cupertino Service Center Shed No. 3C IT Y OF m AGREEMENT CITY OF CUP ERTi NO 10300 Torre Avenue Cupertino, CA 95014 408-777-3200 P .O NO . ?o1 F ,;,;; I C UP E RT INO Th is Agreement ("Agreement") is entered into by and between the City of Cupertino , a municipal co rporation ("City ") and C. Cruz Sub su rface Locato rs, Inc. <name of contractor >, a Cal ifornia corporation <type of business entity> ("Contractor"), effective November 1 , 20~. 1. SERVICES : Contractor will prov ide or furn ish the following services ("Services "): Locate and mark existing util ities with t he proposed work area at t he Cupe rtino Service Center Shed No. 3 <describe services above OR check box and attach Scope of Services as E x hibit A > ~ If checked , the Scope of Services is attached as E x hibit A and incorporated herein. 2. TIME: Contractor must begin providing the Services on November 1, 20 17, and must complete t he Services no later than Dec. 31 , 2012_. This Agreement will e xpire upon satisfactory completion of the Services , unless terminated sooner by City. 3. COMPENSATION: For sa t isfactory performance of the Services , upon receipt of a written invoice , City will pay Contractor as follows : <check one and delete t he unused option> D A lump sum amount of: $ ----·---- ~ At the rate of $150 per hour for a total not to e xceed $ _7_5_0 ____ _ 4. STANDARD OF CARE: All Services must be provided in a manner that meets or exceeds the standard of care applicable to the same type of service in the San Francisco Bay Area. Services may only be performed by qualified and e xperienced personnel who are not employed by the City and who do not · have any contractual relationship with City , with the exception of this Agreement. 5 . INDEMNITY: A. For Design Professional Services Only. To the full extent permitted by law , Contractor will indemnify , defend , and hold harmless City , its governing body , officers , agents , employees , and volunteers from and against any and all liability , loss , damage, claims, expenses and costs (including , without limitation , attorney fees and costs and fees of litigation) (collectively, "Liability ") of every nature which arises out of, pertains to , or relates to the negligence , recklessness , or willful misconduct of Contractor in the performance of this Agreement , except such Liability caused by the active negligence , sole negligence or willful m isconduct of City . This indemnification obligat ion is not limited i n any way by any limitation on the amount or type of damages or compensation payable to or for Contractor or its agents or employees under Workers' Compensation acts , disability benefits acts, or other employee benefit acts . This indemnification obligation is not limited by any limitation on the amount or type of damages available under any applicable insurance coverage and will survive the expiration or early termination of this Agreement with respect to Liabil ity arising during the term of the Agreement. If this Agreement is entered into or amended on or after January 1, 2018, the Contractor's duty to defend will be limited to its proportionate share of fault , as determined by a final , non-appealable decision by a court of competent jurisdiction , subject to any applicable exceptions in Civil Code section 2782 .8 . This subsection A is applicable only if Contractor is a licensed architect, landscape architect, engineer, or land surveyor. 8. For Non-Design Professional Services Only. Contractor will indemnify , defend with counsel acceptable to City , and hold harmless to t he full extent permitted by law , City , its governing body , officers , agents , employees, and volunteers from and against any and all liability , demands, loss , damage , claims , settlements, expenses , and costs (includ i ng , without limitation, attorney fees , expert Agreement for Services Under $5,000 Revised 9-6-17 Page 1 of 4 Approv ed __ witness fees , and costs and fees of litigation) (collectively , "Liability") of every nature arising out of or in connection with Contractor's acts or omissions with respect to this Agreement , except such Liability caused by the active negligence, sole negligence , or willful misconduct of the City . This indemnification obligation is not limited by any limitation on the amount or type of damages or compensation payable under Workers' Compensation or other employee benefit acts, or by insurance coverage limits, and will survive the expirat ion or early termination of this Agreement. This subsection Bis applicable only if Contractor is not a licensed architect, landscape architect, engineer, or land surveyor. 6. SUBCONTRACTING: Contractor has been retained due to its unique skills and Contractor may not substitute another, assign or transfer any rights or obligations under this Agreement. Unless prior written consent from City is obtained, only those people whose names are listed this Agreement may be used in the performance of this Agreement. 7. INSURANCE: A. Coverage. Contractor will, at all times under this Agreement, maintain the following insurance coverage , and will provide City with certificates of insurance and required endorsements as evidence of coverage before performing any Services : Workers' Compensation: Statutory coverage as required by the State of California . If Contractor is self-insured , it must provide its duly authorized Certificate of Permission to Self-Insure . Liability: Commercial general liability coverage in the following minimum limits : Bodily Injury: $500 ,000 each occurrence $1,000,000 aggregate -all other Property Damage : $100,000 each occurrence $250 ,000 aggregate If submitted, combined single limit policy with aggregate limits in the amounts of $1 ,000 ,000 will be considered equivalent to the required minimum limits shown above. Automotive: Commercial automotive liability coverage for owned , non-owned and hired vehicles , in the following minimum limits : Bodily Injury : Property Damage: or $500,000 each occurrence $100,000 each occurrence Combined Single Limit: $500 ,000 each accident Professional Liability: If indicated below, professional liability insurance is required and must include coverage for the professional acts, errors and omissions of Consultant in the amount of at least $500 ,000 per claim and in the aggregate . ~Professional liability insurance~ required for this Agreement. <check if required> B. Subrogation Waiver. Each required policy must include an endorsement that the insurer waives any right of subrogation it may have against the City or the City 's insurers . C. Additional Insured Endorsements. City, its City Council , boards and commissions, officers, officials , employees , agents and volunteers must be named as additional insureds under all insurance coverages, except any worker's compensation and professional liability insurance, required by this Agreement. Any additional insured will not be held liable for any premium , deductible portion of any loss , or expense of any nature on this policy or any extension thereof. Any other insurance held by an additional insured will not be required to contribute anything toward any loss or expense covered by the insurance required under this Agreement. Agreement for Services Under $5,000 Revised 9-6-17 Page 2 of 4 Approved __ _ 8. PERMITS AND LICENSES: Contract or , at its sole expense , must obtain and maint a i n duri ng t he term of this Agreement , all appropriate permits , certificates and licenses including , but not limited to , a City Business License that may be required i n connection with the performance of the Services . A City Business License is not required if the Contractor's sole business contact within the City is the sale of goods or services to the C ity itself. 9. LABOR CODE COMPLIANCE: If Services are "Public Works" as defined under Labor Code Sect ion 1720 et seq ., and the total compensation for the agreement exceeds $1000, the Agreement is subject to all applicable requirements of Chapter 1 of Part 7 of Division 2 of the Labor Code , beginning at Section 1720 , and the related regulations , including but not limited to requirements perta ining to wages , payroll records , working hours and workers ' compensat ion i nsurance . Contractor must also post all job site notices requ ired by laws or regulations pursuant to Labor Code Section 1771.4 . The preva iling wage rates are on file with the C ity Engineer's office and are available online at http://www.dir.ca.gov/D:SR. This Agreement is subject to the requirements of Labor Code sections 1771 , 1775 , 1776 , and 1810-1813. Electronic payroll submission is not required for this Agreement. 10. WORKERS' COMPENSATION CERTIFICATION: Pursuant to Labor Code Section 1861 , by s ign i ng this Agreement , Contractor cert ifies as follows : "I am aware of the provisions of Labor Code Section 3700 which require every employer to be insured aga i nst liability for workers ' compensation or to undertake self-insurance in accordance with the provis ions of that code , and I will comply with such provisions before commencing performance of the Services under this Agreement." 11. TERMINATION OF AGREEMENT: The City reserves the right to termina t e th is Agreement with or without cause with three days written notice to Contractor . 12 . NON-DISCRIMINATION: No discrimination will be made in the employment of persons under this Agreement because of the race , color, national origin, ancestry , re ligion , gender or sexual orientation of such person. 13. INDEPENDENT CONTRACTOR: City and Contractor intend that Contractor w ill perform the Work under this Agreement as an i ndependent contractor. Contractor is solely responsible for it s means and methods in perform i ng the Services . Contractor is not an employee of C ity and is no t entitled to part icipate in health , retirement o r any other employee benefits from City . 14 . COMPLIANCE WITH ALL LAWS: Contractor will comply with all applicable Federal , State , and local laws and ord i nances including, but not limited to , unemployment insurance benefits , FICA laws , and the City business license ordinance . 15. ASSIGNMENT: Contractor may not assign or transfer this Agreement without prior written consent of City . 16 . CHANGES: Th is Agreement may not be amended w ithout the City 's prior written authoriza ti on . 17. INTEGRATION: Th is Agreement and the documents and statutes attached , referenced or expressly i ncorporated herein , including any duly authorized and executed amendments or change orders to the Agreement , constitute the full and complete understanding of every kind o r nature whatsoever between City and Contractor with respect to the Services . 18. INSERTED PROVISIONS: Each provision and clause required by law to be inse rted in this Agreement is deemed to be inserted, and this Agreement will be construed and enforced as though each was included. 19. SERVICES COORDINATOR: The Services Coordinator and representat ive fo r City will be : NAME :A lex Acenas, Public Works Project Manager DEPARTMENT: Public Works Agreement for Services Under $5,000 Revised 9-6-17 Pag e 3 of 4 Approved __ IN WITNESS WHEREOF, the parties have caused the Agreement to be executed , effective on the date written above. CONTRACTOR :yc rn,Sob~ Name: Chris Cruz, Title : 1)yr3C:::1.,·,} t-1.Al Tax 1.0. No .: 11-o,fo Cd~ 'S Address: 105 Serra Way, Ste. 417 Milpitas, CA 95035 Agreement for Servi ces Und er $5 ,000 Revis ed 9-6-17 Title : C U:' MANAEJ€R APPROVED AS TO FORM : .AY Agreement $ 750 _00 Amount: _____________ _ 420-99-034-900-905 -SVCT 004-02-03 Account No.: ___________ _ Page 4 of 4 Approved __ EXHIBIT A C. Cruz Sub-Surface Locators Inc t.rn u 'iY I.OCA JON · L.(AK 0£:i[ Bartos Architecture Attn: Laszlo Petrik Project: City of Cupertino-Material Storage Shed Scope of Work: Locate and mark existing utilities within proposed work area. Quote: Not to exceed 5 hours @$150 per hour. ($750) Notes: 10/26/17 We will scan for any Hot Electrical. We will trace out any conductive utility in the area that we have proper access to. We will trnce out any drain lines that we have proper access to insert a cable in the areas needed. We cannot locate any non-conductive utilities. Everything we locate will be marked with paint. Thank You, Chris Cruz Jr 105 Serra Way, Suite 417 Milpitas, CA 95035 www.CCruzLocators.com Phone: (408) 946-1400 Fax : ( 408) 946-57 42 chris.cruz@comcast.net CCRUZSU-01 MWILL ACORD" CERTIFICATE OF LIABILITY INSURANCE I DATE (MM/DD/Y YYY ) '---" 11/09/2017 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(si. PRODUCER ~ONTACT AME : TSM Insurance & Financial Services rA~8.NJo , Ext): (209) 524-6366 I FA X 1317 Oakdale Rd. Bldg. 910 (A /C, No):(209) 524-6846 E-MAIL Modesto, CA 95355 ADDRESS : INSURER(Sl AFFORDING COVERAGE NAIC# INSURER A : Beazlev Insurance Comoanv Inc. 011442 INSURED INSURER B: United Financial Casualtv Comoanv 11770 C Cruz Sub Surface Locators INSURER c : State Comoensation Insurance Fund 35076 Chris Cruz ' PMB #417 105 Serra Way INSURER D: Milpitas, CA 95035 INSURER E: INSURER F : COVERAGES CERTIFICATE NUMBER· REVISION NUMBER· THIS IS TO CERTIFY THAT THE POLIC IES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDI CATED. NOTWITHSTANDING AN Y REQUIREMENT , TERM OR CONDITION b F AN Y CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERT IFICATE MA Y BE ISSUED OR MA Y PERTAIN , THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS , EX CLUSIONS AND CONDITIONS OF SUCH POLI CIES . LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLA IMS . 1~.p~ TYPE OF INSURANCE ADDL SUBR POLIC Y NUMBER POLICY EFF 1~8~~~".:¥l<!' .. LIMITS •••~n ,..,n A X COMMERCIAL GENERAL LIABILITY EAC H OCC URR ENCE $ 2,000,000 -D CLA IM S-M ADE CR] OCC UR DAMAG E TO RENTED 100,000 X ENC000033101 08/26/2017 08/26/2018 PREMIS ES /Ea occurre nce) $ MED EXP (Anv one oe rsonl $ 5,000 - PERSO NAL & ADV INJURY $ 2,000,000 -2,000,000 GEN 'L AGGREGATE LIMIT APPLIE S PER: GE NERAL AG GRE GATE $ ~ POLI CY O ~f8i' 0 LOC ' PRO DU CTS -CO MP/O P AG G $ 2,000,000 OTHE R: Deductible $ 2,500 B AUTO MOBILE LIABILITY COMB INED SING LE LI MIT 2,000,000 ,_ /Ea oeridentl $ X ANY AU TO 04604113-8 02/05/2017 02/05/2018 BODI LY INJURY (Per oerson l $ -OWN ED -SC HE DU LE D AUTOS ONLY X AUTOS BO DILY INJU RY (Per accident) $ :--/p~?~tc%~~1?AMAG E HI RE D NON-OWN ED $ -AUTOS ONL Y -AUTOS ONL Y $ UMBRELLA LIAB H OCC UR EAC H OCC URREN CE $ - EXCESS LIAB CLAIM S-M ADE AGG REGATE $ OED I I RETENTION $ $ C WORKERS COMPENSATION XI ~ffruTE I I OTH- AND EMPLO YERS" LIABILITY ER YIN 1644488-17 08/30/2017 08/30/2018 1,000,000 ANY PR OPRIETOR/PAR TNE R/EXECUTI VE D E.L. EAC H ACC IDENT $ OFFI CER/MEMB ER EXCL UDED ? N/A 1,000,000 (Mandatory in NH) E.L . DI SEAS E -EA EMP LOY EE $ g~it~ftf[~~ 'g'~'gPERATI ONS below E.L. DI SEASE -PO LI CY LIM IT $ 1,000,000 A Pollution Liability ENC000033101 08/26/2017 08/26/2018 Aggregate Limit 2,000 ,000 A Professional Liab ENC000033101 08/26/2017 08/26/2018 Aggregate Limit 2,000,000 DESCRIPTION OF OPERATIONS / LOCATIONS I VEHICLES tCORD 101 , Additional Remark s Schedul e, ma y be att ac hed if more spa ce is required) The City of Cupertino, inlcuding its City Counci , boards and commisions, officers, officials, agents, employees, consultants and volunteers are named as Additional Insured per the attached endorsements . CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE City of Cupertino THE EXPIRATION DATE THEREOF , NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS . Public Works Dept. 10300 Torre Avenue Cupertino, CA 95014 AUTHORIZED REPRESENTATIVE E1~ V oYl i<.;,t" I ACORD 25 (2016/03) © 1988-2015 ACORD CORPORATION. All rights reserved . The ACORD name and logo are registered marks of ACORD effective date of this endorsement: policy number: ENC 0000331-01 08/26/2017 Endorsement Number: 02 PRIMARY/NON -CONTRIBUTORY-OTHER INSURANCE CONDITION This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE PART All other terms and conditions of this Policy remain unchanged. The following is added to the Other Insurance Condition and supersedes any provision to the contrary: Primary And Noncontributory Insurance This ins~rance is primary to and will not seek contribution from any other insurance available to an additional insured under your policy provided that: CG 20 01 0413 ( 1) The additional insured is a Named Insured under such other insurance; and (2) You have agreed in writing in a contract or agreement that this insurance would be primary and would not seek contribution from any other insurance available to the additional insured. ©Insurance Services Office, Inc. Page ===.:."=====-..::=.==~-==-----===-=--""""-=====--=c ··-. -- effective date of this endorsement: policy number: ENC 0000331-01 08/26/2017 Endorsement Number: 03 ADDITIONAL INSURED-OWNERS, LESSEES OR CONTRACTORS -SCHEDULED PERSON OR ORGANIZATION In consideration of an additional premium of $0, this endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART All other terms and conditions of this Policy remain unchanged. SCHEDULE Name of Additional Insured Person(s) Or Location(s) of Covered Operations Organization(s ): Any person(s) or organization(s) where this All project locations where this endorsement is required by contract. endorsement is required by contract. Information required to complete this Schedule, if not shown above, will be shown in the Declarations. A. Section II -Who Is An Insured is amended to include as an additional insured the person(s) or organization(s) shown in the Schedule, but only with respect to liability for "bodily injury", "property damage" or "personal and advertising injury" caused, in whole or in part, by: 1. Your acts or omissions; or 2. The acts or omissions of those acting on your behalf; in the performance of your ongoing operations for the additional insured(s) at the location(s) designated above. B. With respect to the insurance afforded to these additional insureds, the following additional exclusions apply: CG 20 10 07 04 ©Insurance Services Office, Inc. Page This insurance does not apply to "bodily injury" or "property damage" occurring after: 1. All work, including materials, parts or equipment furnished in connection with such work, on the project ( other than service, maintenance or repairs) to be performed by or on behalf of the additional insured(s) at the location of the covered operations has been completed; or 2. That portion of "your work" out of which the injury or damage arises has been put to its intended use by any person or organization other than another contractor or subcontractor engaged in performing operations for a principal as a part of the same project. CG 20 10 07 04 ©Insurance Services Office, Inc. Page 2 effective date of this endorsement: policy number: ENC 0000331-01 08/26/2017 Endorsement Number: 04 ------··--- ADDITIONAL INSURED -OWNERS, LESSORS OR CONTRACTORS -COMPLETED OPERATIONS In consideration of an additional premium of $0 1 this endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART All other terms and conditions of this Policy remain unchanged. SCHEDULE Name Of Additional Insured Person(s) Or Location And Description Of Completed Organization(s ): Operations Any person(s) or organization(s) where this All project locations where this endorsement is required by contract. endorsement is required by contract. Information required to complete this Schedule, if not shown above, will be shown in the Declarations. Section II -Who Is An Insured is amended to include as an additional insured the person(s) or organization(s) shown in the Schedule, but only with respect to liability for "bodily injury" or "property damage" caused, in whole or in part, by "your work" at the location designated and described in the schedule of this endorsement performed for that additional insured and included in the "products-completed operations hazard". CG 20 37 07 04 ©Insurance Services Office, Inc. Page effective date of this endorsement: policy number: ENC 0000331-01 08/26/2017 Endorsement Number: 06 WAIVER OF TRANSFER OF RIGHTS OF RECOVERY This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART All other terms and conditions of this Policy remain unchanged. SCHEDULE Name of Person or Organization: Any person(s) or organization(s) where this endorsement is required by contract. All Person(s) Or Organization(s) where this endorsement is required by contract. {If no entry appears above, information required to complete this endorsement will be shown in the Declarations as applicable to this endorsement.) The TRANSFER OF RIGHTS OF RECOVERY AGAINST OTHERS TO US Condition (Section IV- COMMERCIAL GENERAL LIABILITY CONDITIONS) is amended by the addition of the following: We waive any right of recovery we may have against the person or organization shown in the Schedule above because of payments we make for injury or damage arising out of your ongoing operations or "your work" done under a contract with that person or organization and included in the "products-completed operations hazard". This waiver applies only to the person 'or organization shown in the Schedule above. CG 24 0410 93 ©Insurance Services Office, Inc. Page 1 -STATE -ENDORSEMENT AGREEMENT WAIVER OF SUBROGATION BLANKET BASIS BROKER COPY COMPENSATION INSURANCE -FOND- HOME OFFICE SAN FRANCISCO ALL EFFECTIVE DATES ARE AT 12:01 AM PACIFIC STANDARD TIME OR THE TIME INDICATED AT PACIFIC STANDARD TIME EFFECTIVE AUGUST 30, 2017 AT 12.01 A.M. AND EXPIRING AUGUST 30, 2018 AT 12.01 A.M. CHRIS CRUZ SUB SURFACE LOCATORS,IN PMB #417 105 SERRA WAY MILPITAS, CA 95035 WE HAVE THE RIGHT TO RECOVER OUR PAYMENTS FROM ANYONE LIABLE FOR AN INJURY COVERED BY THIS POLICY. WE WILL NOT ENFORCE OUR RIGHT AGAINST THE PERSON OR ORGANIZATION NAMED IN THE SCHEDULE . THIS AGREEMENT APPLIES ONLY TO THE EXTENT THAT YOU PERFORM WORK UNDER A WRITTEN CONTRACT THAT REQUIRES YOU TO OBTAIN THIS AGREEMENT FROM US. THE ADDITIONAL PREMIUM FOR THIS ENDORSEMENT SHALL BE 2.00% OF THE TOTAL POLICY PREMIUM. SCHEDULE PERSON OR ORGANIZATION ANY PERSON OR ORGANIZATION FOR WHOM THE NAMED INSURED HAS AGREED BY WRITTEN CONTRACT TO FURNISH THIS WAIVER JOB DESCRIPTION BLANKET WAIVER OF SUBROGATION NOTHING IN THIS ENDORSEMENT CONTAINED SHALL BE HELD TO VARY, ALTER, WAIVE OR EXTEND ANY OF THE TERMS, CONDITIONS, AGREEMENTS, OR LIMITATIONS OF THIS POLICY OTHER THAN AS STATED. NOTHING . ELSEWHERE IN THIS POLICY SHALL BE HELD TO VARY, ALTER, WAIVE OR LIMIT THE TERMS, CONDITIONS, AGREEMENTS OR LIMITATIONS OF THIS ENDORSEMENT. COUNTERSIGNED AND ISSUED AT SAN FRANCISCO: ~~,q AUGUST 31, 2017 d-, .. ~ _dl;,,~ PRESIDENT AND CEO SCIF FORM 10217 IREV.7-2014) 1644488-17 RENEWAL NF 0-52-26-05 PAGE 1 OF 2572 OLD DP 217 1 Cert ifi cate Holder TS M INS AGENCY 1317 OAKDALE RD# 910 MO DESTO, CA 95355 1-209-52 4-6366 Certificate of Insurance PROGREIIIVE" COMMERCIAL Policy number: 04604113-8 Under written by: UNITED FINANCIAL CASCO November 14, 2017 Page 1 of 2 ............................................................................................................................................................................................... Additiona l Insured CITY OF CUPERTINO 10300 TORRE AVE CUPERTINO, CA 95014 I nsu red ................. . .................................... . CRUZ SUB SURFACE LOCA TERS PMB #417, 105 SERRA MIL PITAS, CA 95035 . /\gent ...... .. TSM INS AGENCY 1317 OAKDALE RD # 910 MODESTO, CA 95355 This document cert ifies that insurance po licies identified be low have been issued by the designated insurer to the insured named above for the period(s) ind icated . This Certificate is issued for information purposes on ly. It confers no rights upon the certificate holder and does not change, alter, mod ify, or extend the coverages afforded by the po licies listed be low. The coverages afforded by t he po li cies listed below are subject to all the terms, exclusions, limitations, endorsements, and conditions of these policies . ............. ·····················. .................................. . ...................................................................... .. Po li cy Effective Date: Feb 5, 2017 Po licy Expiration Date: Feb 5, 20 18 Insurance cover age(s) Lim its ................ BOD IL Y INJURY/PROPERTY DAMAGE $2,000,000 COMB INED SINGLE LIM IT ............... ..... ................ ........................... . ........................ . UN INSURED/UNDERINSURED MOTORIST $2,000,000 COMBINED SINGLE LIMIT ............ . ......................... . ANY AUTO BODILY INJURY/PROPERTY DAMAGE $2,000,000 COMBINED SING LE LIM IT Description of Location/Vehicles/Special Items ~~~~~ ll .1.ed.. c1~to.s <>.n.ly ................. . 2008 CHEVROLET EXPRESS G1500 1GCFG154381145756 MED ICA L PAYMENTS $5,000 COMPRE HENS IVE $500 DED CO LLI SION $500 W/WA IVER DED ..... . .................................................................................................... . 2008 FORD ECONO/CLUB WGN 1 FTNE24WX8DA88478 MED ICAL PAYMENTS $5,000 COMPR EHENSIVE $500 DED COL LI SION $500 W/WAIVER DED 2016 FORD T-250 TRAN SIT V 1 FTYR1 YM8 GKB06071 MEDICAL PA YMENTS COMPREHENSIVE COLLIS ION $5,000 $500 DED $500 W/WAIVER DED Stated Amount $37,314 ll Continuea ...... . ................................................................................ . 2017 GMC SIERRA C3500 /K3 1 GT42YEY2 HF 201724 MED ICAL PAYMEN TS COMPREHEN SIVE CO LLI SION Certificate number 31817NET113 $5,000 $500 OED $500 W/WAIVER OED Policy number: 04604113-8 Page 2 of 2 Please be advised that additional insureds and loss payees will be notified in the event of a mid-term cancellation. Form 524 1 (10/02)