Page 73 - Willow Park Estates Closeout Manual

DATE (MM/DD/YYYY)
CERTIFICATE OF LIABILITY INSURANCE 4/12/2017
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 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).
PRODUCER CONTACT Certificate Department
NAME:
Cavignac & Associates PHONE 619-744-0574 FAX
450 B Street, Suite 1800 (A/C, No, Ext): (A/C, No): 619-234-8601
San Diego CA 92101 E-MAIL certificates@cavignac.com
ADDRESS:
INSURER(S) AFFORDING COVERAGE NAIC #
INSURER A :United Specialty Insurance Co
INSURED JWCCONS-01 INSURER B :Travelers Property & Casualty Compa 25674
JWC Construction Inc. INSURER C :Crum & Forster Specialty Ins.
d.b.a. Jon Wayne Construction & Consulting
2580 Fortune Way INSURER D :
Vista CA 92081-8441 INSURER E :
INSURER F :
COVERAGES CERTIFICATE NUMBER: 122762752 REVISION NUMBER:
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.
INSR ADDL SUBR POLICY EFF POLICY EXP
LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER (MM/DD/YYYY) (MM/DD/YYYY) LIMITS
A X COMMERCIAL GENERAL LIABILITY Y ATNSF1720114 1/1/2017 1/1/2018 EACH OCCURRENCE $1,000,000
DAMAGE TO RENTED
CLAIMS-MADE X OCCUR PREMISES (Ea occurrence) $50,000
X Defense outside MED EXP (Any one person) $
X Separation of In PERSONAL & ADV INJURY $1,000,000
GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $2,000,000
POLICY X PRO- LOC PRODUCTS - COMP/OP AGG $2,000,000
JECT
OTHER: BI/PD Deduct. $ 10,000
B AUTOMOBILE LIABILITY Y 8106G236336 1/1/2017 1/1/2018 COMBINED SINGLE LIMIT $ 1,000,000
(Ea accident)
X ANY AUTO BODILY INJURY (Per person) $
ALL OWNED SCHEDULED
AUTOS AUTOS BODILY INJURY (Per accident) $
NON-OWNED PROPERTY DAMAGE
HIRED AUTOS AUTOS (Per accident) $
$
UMBRELLA LIAB OCCUR EACH OCCURRENCE $
EXCESS LIAB CLAIMS-MADE AGGREGATE $
DED RETENTION $ $
B WORKERS COMPENSATION UB6G236336 1/1/2017 1/1/2018 X PER OTH-
ER
STATUTE
AND EMPLOYERS' LIABILITY Y / N
ANY PROPRIETOR/PARTNER/EXECUTIVE E.L. EACH ACCIDENT $1,000,000
OFFICER/MEMBER EXCLUDED? N / A
(Mandatory in NH) E.L. DISEASE - EA EMPLOYEE $1,000,000
If yes, describe under
DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT $1,000,000
C Professional/Pollution Liab. PKC104730 1/1/2017 1/1/2018 Each Claim $1,000,000
Aggregate $1,000,000
DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required)
Re: Prescott Lakes (Northridge Drive & Crown Ridge Drive) Prescott, Arizona 86301. Additional Insured coverage applies to General Liability
and Automobile Liability for Willow Park Estates per policy form. Professional Liability - Claims made form, defense costs included within limit.
If the insurance company elects to cancel or non-renew coverage for any reason other than nonpayment of premium Cavignac & Associates
will provide 30 days notice of such cancellation or nonrenewal.

CERTIFICATE HOLDER CANCELLATION

SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
Willow Park Estates THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
c/o Chelsea Walton ACCORDANCE WITH THE POLICY PROVISIONS.
HOAMCO
3205 Lakeside Village
Prescott AZ 86301 AUTHORIZED REPRESENTATIVE

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