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Insurance Certificates 2024/25 SAVI Construction, Inc
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. INSURER(S) AFFORDING COVERAGE INSURER F : INSURER E : INSURER D : INSURER C : INSURER B : INSURER A : NAIC # NAME:CONTACT (A/C, No):FAX E-MAILADDRESS: PRODUCER (A/C, No, Ext):PHONE INSURED REVISION NUMBER:CERTIFICATE NUMBER:COVERAGES 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). 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. OTHER: (Per accident) (Ea accident) $ $ N / A SUBR WVD ADDL INSD 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. $ $ $ $PROPERTY DAMAGE BODILY INJURY (Per accident) BODILY INJURY (Per person) COMBINED SINGLE LIMIT AUTOS ONLY AUTOSAUTOS ONLY NON-OWNED SCHEDULEDOWNED ANY AUTO AUTOMOBILE LIABILITY Y / N WORKERS COMPENSATION AND EMPLOYERS' LIABILITY OFFICER/MEMBER EXCLUDED? (Mandatory in NH) DESCRIPTION OF OPERATIONS below If yes, describe under ANY PROPRIETOR/PARTNER/EXECUTIVE $ $ $ E.L. DISEASE - POLICY LIMIT E.L. DISEASE - EA EMPLOYEE E.L. EACH ACCIDENT EROTH-STATUTEPER LIMITS(MM/DD/YYYY)POLICY EXP(MM/DD/YYYY)POLICY EFFPOLICY NUMBERTYPE OF INSURANCELTRINSR DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) EXCESS LIAB UMBRELLA LIAB $EACH OCCURRENCE $AGGREGATE $ OCCUR CLAIMS-MADE DED RETENTION $ $PRODUCTS - COMP/OP AGG $GENERAL AGGREGATE $PERSONAL & ADV INJURY $MED EXP (Any one person) $EACH OCCURRENCE DAMAGE TO RENTED $PREMISES (Ea occurrence) COMMERCIAL GENERAL LIABILITY CLAIMS-MADE OCCUR GEN'L AGGREGATE LIMIT APPLIES PER: POLICY PRO-JECT LOC CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DD/YYYY) CANCELLATION AUTHORIZED REPRESENTATIVE ACORD 25 (2016/03) © 1988-2015 ACORD CORPORATION. All rights reserved. CERTIFICATE HOLDER The ACORD name and logo are registered marks of ACORD HIRED AUTOS ONLY 20443Continental Casualty Company A 10914Kemper Independence Insurance Company B 4/1/2025 (951)694-0625 (951)719-3350 Phone: Fax: PSA Realty & Insurance Services PO Box 720 Temecula, California 92593-0720 Savi Construction Inc 6725 Birmingham Drive Chino, CA 91710 4 4 4 C6987215040 12/2/2024 12/2/2025 1,000,000 100,000 5,000 1,000,000 2,000,000 2,000,000 4 50020373901 12/16/2024 6/16/2025 1,000,000 1,000,000 1,000,000 CITY OF LA QUINTA Holder's Nature of Interest : Additional Insured 78-495 CALLE TAMPICO LA QUINTA, CA 92253 4 Certificate Department (951)694-0625 (951)719-3350 certs@psainsurance.com N N City of La Quinta is named as an additional insured with primary included, when required by written contract per company form CNA97587XX 3-2022 attached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o):(A/C, No, Ext): E-MAIL ADDRESS: 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 COMPENSATION AND 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 SAVIC-1 OP ID: JC 05/20/2025 David Katz Visual Media Alliance Ins Svcs 665 Third Street, Suite 500 San Francisco, CA 94107-1990 David Katz 800-659-3363 415-520-1126 Endurance Assurance Corp. Savi Construction Inc. Ramesh Bachuvala 6725 Bermingham Drive Chino, CA 91710 XA X EAW00002031-00 08/15/2024 08/15/2025 1,000,000 EVIDENCE ONLY 1,000,000 1,000,000 QUINTA0 City of La Quinta 78-495 Calle Tampico La Quinta, CA 92253 800-659-3363 WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 04 03 06 (Ed. 4-84) WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT-CALIFORNIA 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.) You must maintain payroll records accurately segregating the remuneration of your employees while engaged in the work described in the Schedule. The additional premium for this endorsement shall be 5% of the California workers’ compensation premium otherwise due on such remuneration. Schedule Person or Organization Job Description City of La Quinta 78495 Calle Tampico La Quinta, CA 92253 Job Address: Various locations within the city of La Quinta Start Date: 06/02/2025 Duration: 20 days Work being performed: Remove and replace sidewalk, curb, & gutter and ADA ramps. # of insured's EEs: 4 Est. Payroll: $99,000 This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated (The information below is required only when this endorsement is issued subsequent to preparation of the policy.) Endorsement Effective 08-15-2024 Policy No. EAW00002031-00 Endorsement No. 4 Insured Savi Construction Inc. (a Corp)Insurance Company Endurance Assurance Corporation Countersigned By ©1998 by the Workers’ Compensation Insurance Rating Bureau of California. All rights reserved. WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 89 06 00 B (Ed. 7-01) POLICY INFORMATION PAGE ENDORSEMENT The following item(s) □ Insured’s Name (WC 89 06 01) □ Item 3.B. Limits (WC 89 06 12) □ Policy Number (WC 89 06 02) □ Item 3.C. States (WC 89 06 13) □ Effective Date (WC 89 06 03) □ Item 3.D. Endorsement Numbers (WC 89 06 14) □ Expiration Date (WC 89 06 04) □ Item 4.* Class, Rate, Other (WC 89 04 15) □ Insured’s Mailing Address (WC 89 06 05) □ Interim Adjustment of Premium (WC 89 04 16) □ Experience Modification (WC 89 04 06) □ Carrier Servicing Office (WC 89 06 17) □ Producer’s Name (WC 89 06 07) □ Interstate/Intrastate Risk ID Number (WC 89 06 18) □ Change in Workplace of Insured (WC 89 06 08) □ Carrier Number (WC 89 06 19) □ Insured’s Legal Status (WC 89 06 10) □ Issuing Agency/Producer Office Address (WC 89 06 25) □ Item 3.A. States (WC 89 06 11) is changed to read: *Item 4. Change To: Classifications Code No. Premium Basis Total Estimated Annual Remuneration Rate Per $100 of Remuneration Estimated Annual Premium Total Estimated Annual Premium $ Minimum Premium $ Deposit Premium $ All other terms and conditions of this policy remain unchanged. This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated. (The information below is required only when this endorsement is issued subsequent to preparation of the policy.) Endorsement Effective Policy No. Endorsement No. Insured Premium 3ROLF\(IIHFWLYH Insurance Company Countersigned by___________________________________________ WC 89 06 00 B (Ed. 7-01) © 2001 National Council on Compensation Insurance, Inc. 4,322 X Adding Waiver of Subrogation for City of La Quinta 4 Included Savi Construction Inc. (a Corp) EAW00002031-00 08-15-2024 08-15-2024 Endurance Assurance Corporation WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 04 00 05 (Ed. 07-98) EXTENSION OF INFORMATION PAGE Classifications Item 4 Policy No. EAW00002031-00 CLASSIFICATION OF OPERATIONS Estimated Rate Estimated Remuneration Per $100 Premium CALIFORNIA TOTAL Rating Period 08-15-2024 through 08-15-2025 Location 1 5205 Concrete or Cement Work - Floor Slabs - Greater than or = $32/hr $40,000 8.84 $3,536 Location 1 Total $3,536 0930 Waiver of Subrogation - City of Laguna Niguel 30111 Crown Valley Parkway Laguna Niguel, CA 92677 $ 0930 Waiver of Subrogation - City of Solana Beach 635 Hwy 101 Solana Beach, CA 92075 $ 0930 Waiver of Subrogation - City of La Quinta 78495 Calle Tampico La Quinta, CA 92253 $ 0 Employers Liability Limits 1.000 $ 9898 Experience Modificator .00 $ 9724 Policy Debit - New Venture .10 $354 9887 Schedule Modification 1.00 $ Rating Period 08-15-2024 through 08-15-2025 0063 Premium Discount 1.0000 $ 0900 Expense Constant $400 9741 Catastrophe Premium 0.04 $16 9740 Terrorism Risk Insurance Act Premium 0.04 $16 Written Premium $4,322 9999 Workers Comp. Admin. Revolving Fund Assessment (WCARF)0.024604 $106 9999 Workers Comp. Fraud Account Assessment (FRAUD)0.004122 $18 9999 Uninsured Employers Benefits Trust Fund Assessment (UEBT)0.001505 $7 9999 Subsequent Injuries Benefits Trust Fund Assessment (SIBT)0.015891 $69 9999 Occupational Safety and Health Fund Assessment (OSHF)0.007266 $31 9999 Labor Enforcement & Compliance Fund (LECF)0.007109 $31 Policy Fee $ Rating Period Total $4,584 CALIFORNIA TOTAL $4,584 POLICY TOTAL $4,584 WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 04 00 05 (Ed. 07-98) WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 04 03 06 (Ed. 4-84) WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT-CALIFORNIA 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.) You must maintain payroll records accurately segregating the remuneration of your employees while engaged in the work described in the Schedule. The additional premium for this endorsement shall be 5% of the California workers’ compensation premium otherwise due on such remuneration. Schedule Person or Organization Job Description City of La Quinta 78495 Calle Tampico La Quinta, CA 92253 Job Address: Various locations within the city of La Quinta Start Date: 06/02/2025 Duration: 20 days Work being performed: Remove and replace sidewalk, curb, & gutter and ADA ramps. # of insured's EEs: 4 Est. Payroll: $99,000 This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated (The information below is required only when this endorsement is issued subsequent to preparation of the policy.) Endorsement Effective 08-15-2024 Policy No. EAW00002031-00 Endorsement No. 4 Insured Savi Construction Inc. (a Corp)Insurance Company Endurance Assurance Corporation Countersigned By ©1998 by the Workers’ Compensation Insurance Rating Bureau of California. All rights reserved.