Insurance-Heitkamp Inc - 2013-08-07d Gf`C ii irii
LJ AfN °® CERTIFICATE OF LIABILITY INSURANCE Et e,, L1
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,
0 1 7/2013
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON HE M11FICATE HOLDER. THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER TH %LQgMffM% THE POLICIES
��BY
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING I (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
Willis of New York, Inc.
c/o 26 century Blvd,
CONTACT
NAME:
PHONE FAX
ac No. Exr: 877- 945 -7378 fAI C No: 888- 467 -2378
P. O. Box 305191
Nashville, TN 37230 -5191
NES& certificates@willis.com
INSURER(S)AFFORDING COVERAGE
NAICN
7/1/2013
INSURERA: Tokio Marine & Nichido Fire Insurance Co.
12904 -001
$ 11000,000
INSURED
Heitkamp, Inc.
INSURERS:
INSURERC:
Mesa,
99 Callender Road
P.O. Box 730
Watertown, CT 06795
INSURER D:
INSURER E:
$ 10,000
INSURER F:
COVERAGES CERTIFICATE NUMBER: 20220612 REVISION NUMRER-
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.
LTR
TYPEOFINSURANCE
DD'
SUB
D
POLICYNUMBER
POLICY EFF
(MMIDDMYYI
POLICY EXP
IMMMDNM)
LIMITS
A
GENERAL LIABILITY
Y
AUTHORI DR SENTA
CLL6403632 -05
7/1/2013
7/1/2014
EACHOCCURRENCE
$ 11000,000
DAMAGE TO RENTED
PREMISES Ea o.cumncel
$ 11000,000
X COMMERCIAL GENERAL LIABILITY
Mesa,
CA 92627
M ED EXP(Any one person)
$ 10,000
CLAIMS -MADE OCCUR
PERSONAL &ADV INJURY
$ 11000,000
GENERAL AGGREGATE
GEN'L AGG REGALE LIMIT APPLI ES PER:
PRODUCTS- COMP /OPAGG
X POLICY P90T LOC
A
AUTOMOBILE
LIABILITY
Y
CA6402924 -04
7/1/2013
7/1/2014
C MBINED SINGLE LIMIT (Ea accident)
X
BODILY INJURY(Per person)
M2.00O,000
ANYAUTO
ALLOWNED SCHEDULED AUTOS AUTOS
BODILY INJURY(Per accident)
HIREDAUTOS NON-OWNED
AUTOS
PERTV DAMAGE
Peraccident
•
X
UMBRELLALIAB
X
OCCUR
CU 6402931 -04
7/1/2013
7/1/2014
EACHOCCURRENCE
$ 5,000,000
AGGREGATE
$ 5,000,000
EXCESS LIAR
CLAIMS -MADE
DED I I RETENTION$
$
•
WORKERS COMPENSATION
AND EMPLOYERS' LIABILITY Y/N
ANY PROPRIETOR/PARTNEIVEXECUTIVE M
OFFICER/MEMBER EXCLUDED?
NIA
WC6402973 -04
7/1/2013
7/1/2014
X y IMITS H
E.L. EACH ACCIDENT
$ 1,000,000
--
E.L. DISEASE - EA EMPLOYEE
$ 1,000,000
(MandataryinNH)
ff yes, tlescribe under
E. L. DISEASE - POLICY LIMIT
$ 1,000,000
DESCRIPTION OF OPERATIONS below
DESCRIPTION OF OPERATIONS/ LOCATIONS/ VEHICLES (Attach Acord 101, Additonal Remarks Schedule, if more space is required)
Division /Location: Pipe Lining Division
Re: Prequalification
Costa Mesa Sanitary District is included as an Additional Insured as respects to General Liability
and Auto Liability as required by written contract.
CERTIFICATE HOLDER CANCELLATION
Coll:4177647 Tpl:1670941 Cert:20220612 0,1088-2010 ACORD CORPORATION. All rights reserved.
ACORD 25 (2010/05) The ACORD name and logo are registered mark of ACORD
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
Costa
Mesa
Sanitary District
AUTHORI DR SENTA
Attn:
Dyana
Wick
628 W.
19th
Street
Costa
Mesa,
CA 92627
Coll:4177647 Tpl:1670941 Cert:20220612 0,1088-2010 ACORD CORPORATION. All rights reserved.
ACORD 25 (2010/05) The ACORD name and logo are registered mark of ACORD