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Insurance-Municipal Underground - 2012-12-28A rrson �..,... "�'" CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDD/YYYY) 12/28/2012 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 POLL C E I V E D BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHO `PRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. .PORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject t the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the dp p certificate holder in lieu of such endorsement(s). bu,)IA U10A WHARY 01SIRIQ PRODUCER Orion Risk Management Insurance Services, Inc. Ca. Lic. #OD28764 2280 Wardlow Circle, Suite 250 Corona, CA 92880 CONTACT NAME: aDOnrm,Ext:951.736.9477 I uD NO: 951. 736.9478 E -MAIL ADDRESS: PRODUCER OQgp1641 USTOMER ID #: INSURER(S) AFFORDING COVERAGE NAIC# INSURED INSURER A: Colony Insurance Co. /RT Specialty EACH OCCURRENCE Municipal Underground Services, Inc. INSURERS: $ 100,000 28511 Breckenridge Drive INSURER C: PERSONAL &ADV INJURY Laguna Niguel, CA 92677 INSURER D: INSURER E: $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: Poucv X JO LGC INSURER F: $ 2,000,000 COVERAGES CERTIFICATE NUMBER: 12 -14 GL 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 LTR TYPE OF INSURANCE ADDL NOR SUER WVD POLICY NUMBER POLICYEFF MMIDD/YYYY POLICYEXP MM/DD /YYYY LIMITS A GENERAL LIABILITY X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE OCCUR GL95213212129/2012 PER PROJECT AGGREGATE CAPPED AT $5,000,00 12129/2014 EACH OCCURRENCE $ 1,000,000 PREMISES Ea occurrence) $ 100,000 MEO EXP(Anyone person) $ 5,000 PERSONAL &ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: Poucv X JO LGC PRODUCTS- COMP /OP AGG $ 2,000,000 $ AUTOMOBILE LIABILITY ANY AUTO ALL OWNED AUTOS SCHEDULED AUTOS HIREDAUTOS NON -OWNED AUTOS COMBINED SINGLE LIMIT (Ea accident) $ BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ PROPERTY DAMAGE (Per accid nit $ $ UMBRELLA LIAR EXCESS LIAB OCCUR CLAIMS -MADE EACH OCCURRENCE $ AGGREGATE $ DEDUCTIBLE RETENTION $ $ $ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY YIN ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? (Mandatory in NH) If yes, d escribe under DESCRIPTION OF OPERATIONS below NIA WC STATU- OTH- TORY LIMITS I I ER E.L. EACH ACCIDENT $ E.L. DISEASE - EA EMPLOYE $ E.L. DISEASE- POLICY LIMIT $ DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, If more space is required) ertificate holder is named as additional insured subject to the terms of the attached general liability endorsement. 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 �\ AUTHORIZED REPRESENTATIVE 628 W. 19th St. Co to Mesa, CA 92627 Victoria Codis oti, CISR/VAC ©1988.2009 ACORD CORPORATION. All riahfs reserved_ ACORD 25 (2009/09) The ACORD name and logo are registered marks of ACORD NAMED INSURED: MUNICIPAL UNDERGROUND SERVICES, INC. POLICY NUMBER: GL952132 POLICY TERM: 12/29/2012 — 12/29/2014 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. �..- This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Name of Additional Insured Person(s) or Organization(s) Additional Insured): Locations of Covered Operations: ALL PERSONS OR ORGANIZATIONS AS REQUIRED BY AS DESIGNATED IN WRITTEN CONTRACT WRITTEN CONTRACT WITH THE NAMED INSURED. WITH THE NAMED INSURED. 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 for whom you are performing operations when you and such person or organization have agreed in writing in a contract or agreement that such person or organization be added as an additional insured on your policy. Such person or organization is an additional insured 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. A person's or organization's status as an additional insured under this endorsement ends when your operations for that additional insured are completed. B. With respect to the insurance afforded to these additional insureds, the following additional exclusions apply: This insurance does not apply to: Additional Insured Contractual Liability "Bodily injury" or "property damage" for which the additional insured(s) are obligated to pay damages by reason of the assumption of liability in a contract or agreement. Finished Operations at Work "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 U156P -0310 includes copyrighted material of ISO Properties, Inc., Page 1 of 2 with its permission. 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. Negligence of Additional Insured "Bodily injury" or "property damage" arising directly or indirectly out of the negligence of the additional insured(s). C. SECTION IV — COMMERCIAL GENERAL LIABILITY CONDITIONS, 4. Other Insurance is amended and the following added: The insurance afforded by this Coverage Part for the additional insured shown in the Schedule is primary insurance and we will not seek contribution from any other insurance available to that additional insured. ALL OTHER TERMS AND CONDITIONS OF THE POLICY REMAIN UNCHANGED. U156P -0310 Includes copyrighted material of ISO Properties, Inc., Page 2 of 2 with its permission. Jan 2413 11:33a M.U,S.1. 949- 423 -6614 POLICYHOLDER COPY p.1 SG PO. 80X 8192, PLEASANTON, CA 94588 CERTIFICATE OF WORKERS' COMPENSATION INSURANCE ISSUE DATE: 11 -05 -2012 COSTA MESA SANITARY DISTRICT 828 U 19TH ST COSTA MESA CA 92627 -2716 GROUP: POLICY NUMBER 1714355 -2012 CERTIFICATE ID: 65 CERTIFICATE EXPIRES: 11 -OS -2013 11 -05- 2012/11 -05 -2013 SG JOB!COSTA MESA SANITARY DISTRICT 628 M. 19TH STREET COSTA MESA CA 82627 -27le This is to certify that we have issued a valid Workers' Compensation Insurance policy in a form approved oy the California Insurance Comm,ssione- to the employer named below for the policy period indicated. This policy is not sabject In cancellation by the Fund except upon 30 days advance written notice to the emp. dyer. We will also give you 30 days advance notice should this policy be cancelled prior to '.Ls norma! expiral!or. This certificate of insurance is not an insurance policy and does not amend, extend or alter the coverage afforded by the poicy listed herein. Notwithstanding arty requirement, term or condition of any contract or other document wrh respect to which this certificate of insurance may be issued or to which it may pertain, the insurance afforded by the pobcy described herein is subjoct to all the terms, exclusions, and conditions, of such policy. Authorized Representative President and CEO EMPLOYER'S LIABILITY LIMIT INCLUDING DEFENSE COSTS: $1,000,000 PER OCCURRENCE. ENDORSEMENT 61600 - DAVID BOUTELLE, PRIES - EXCLUDED, ENDORSEMENT 61600 - ANN BOUTELLE, VP SEC TRES - EXCLUDED. ENDORSEMENT 62065 ENTITLED CERTIFICATE HOLDERS' NOTICE EFFECTIVE 11 -05 -2003 IS ATTACHED TO AND FORMS A PART OF THIS POLICY. EMPLOYER MUNICIPAL UNDERGROUND SERVICES, INC 28511 BRECKENRIDGE DR LAGUNA NIGUEL CA 92677 IREV. I -20 121 SG ,PiXSGI PRINTED : 01- 24-2013 TAN -24 -2013 11:43 949 429 6614 94: P.01 Jan 24 13 11:33a M.U.S.I. 949- 429 -6614 p.2 H�laf[LJy CERTIFICATE OF LIABILITY INSURANCE /1 aATEUOnnrrY) 84pA7/2012 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 NDTCONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER AND THE CERTIFICATE HOLDER IMPORTANT: If the cerdfli a holder is an ADDITIONAL INSURED, the pofiWy les) must be endorsed. If SUBROGATION O'WAIVED. subject In the II and comOlons of the policy. certain polities may isgUire an endorsement. A statement on this oerfifiale does nA confer rights to the . mflcate holder In feu of such endp. .1emunt(s). PRODUCER Orion Risk Management Insurance Services, Inc. Ca. Lic. 90028764 2280 Wardlow Circle, Suite ZSO Corona, CA 92880 NAM P'- I _"m .951.736.9477 uc N„951.736.9478 EA 01, ARDRESS: WO-UMCEIRIP& 00001641 INSIIREIi(G)AFFOROING LOVEPAGE micN INSURED Municipal Underground Services, Inc. 26511 Breckenridge Drive Laguna Niguel, CA 92677 INSURt:RA: E14C Insurance Companies INSUREIRB: INSUREFI 5 INSURER O: I E _ INSURER E - S INSURERF: Is COVERAGES CERTIFICATE NUMBER: 12 -15 Auto REVISION NUMBER: TI -CS 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 DOCUMEI.T V4FrH RESPECT TO WHICH THIS CERTIRCATE MAYBE ISSUED OR MAY PERTAIN, -HE INSURANCE AFFORDED BY THE POL CIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. LTR _ - -- TYPE OF INSURANCE INS'YNO PODGYWJGBER IAlm FF PO EXP _ LUADs Evildence of Insurance G?r_RAL LIADrIl(Y COPANERCWL GENERN_UABILnY CVdM os❑OCCUR I EACH OCCi1HRENCE 5 PRVAI E' TE1 a . nc I E MEn FWP(Apy ene P.) S PERSOR¢ &AWINJURY Is DENERA•. AGGREGATE b GENL AGGREGATE LN11T APPLIES PER i PSLIC'f ! Tcoi roC PRODUCTS. LOEIP(pP Aru E E _ A AUTOMOBILE UAeArTY X .ANYA O ALL OWNED AUTOS j s,^,HEouLEC Gums ron n AUros rxx WD WNEDFUTOS I 4E43249 8411812012 04/18/2073 M.011,1ED SINGLE UMIY fEa alr�m) S 1 wo, coo -' -- ¢ ILYINJURY(Perpersm) E BODILY INA•RY(PeraWdeil) E p'or>ErrY DAMAGE (�r��Nl S ; E E UTAaRELLA DAB FlCE55 uAa OCCUR CWMSLMOE :ALH OCCURRENCE E AGGREGATE E U OUCTSAF RETENTION $ E E WORKERS COMPENSATION ANDEMPLOYERSUABIUTY YIN ANV ❑ DP-ICERJPCe 30Z=LUDFD? (NpnEVlerymNH) K •.desmaeunder D SCRIPTIQN OF DPERATICtG btlmv NIA 'NC STATU OTH- T dAJi LL EAGi A0BmENT E E.L. DIEEA3E -EA EMPLOYIEF — b ELDIBEAEE- POIrCY LIMIT g DESCRI PnON OP OPERATIONS I LOCHTIONSIYEHJC S(AttachA RD IDS, Addinomal Rmf SplNdule, if more spxe is mpulred) CERTIFICATE HOLDER CANCELLATION ACORD 25 (2009109) l9 998 &2008 ACORD CORPORATION- All rights resirmetl, The ACORD name and 109D are registered marks of ACORD JAN-24-2013 11:43 949 429 6614 94% P.02 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AMOR12£0 REPRESENTATIVE 611,40 Evildence of Insurance Victoria CDdis oti, CISR/VAC ACORD 25 (2009109) l9 998 &2008 ACORD CORPORATION- All rights resirmetl, The ACORD name and 109D are registered marks of ACORD JAN-24-2013 11:43 949 429 6614 94% P.02 Jan 24 13 11:33a h4.U.S.I. 949 -429 -6614 p.3 ACORN. INSURANCE BINDER This supersedes and corrects bATE iMµ' ➢D YYY } Binder 612041703457 1 04/17/2012 THIS BINDER M A TEMPORARY INSURANCE CONTRACT, SUBJECT TO THE CONDITIONS SHOWN ON THE REVERSE SIDE OF THIS FORM. AGENCY COMPANY �BINOE,g Orion Risk Management Insurance Services, Inc. EMC Insurance Companies 1812041703458 Ca. Lic. 90028764 DATE EFFECTIVE TIME DATE 2280 Ward]DW Circle, Suite 2S0 04/16/2012 X 12:01 ^� AM X D6/18J201Z IZD -_ AM IIN,,ON Corona, CA 92880 `PFOYEKTY DANV.G= ___I_S _.__ PM � NGON '(hG NteP. U51.736.9477 N X51.736.9478 Extk A!C I THIS 55UW T IN m COMPANY I PCRI XPIRNG OLCR O ESIGTLEy N,O Ag 6LRCal CODE fl.6 WOC AGENCY ER DO6 CU CM lTHE O IP ROOVPEERRTGY G roNAnM) AttacF DP N LSSt Ce hed t NSURFD IMuinicipal Underground Services, Inc. Aljt AL CA t!VAI.UE_ 28511 Breckenridge Drive Laguna Niguel, C4 92677 GARAGE LIABILITY i ANY AUTO COVERAGES LIMITS TYRE OF IYSURANC -t OF IOE t COVERAGYrORMS DEDUOTIOL° - ,_COING. %. _._._.A90UNT PROPERTY SS E � 1 BASIC I— eFI I_ SPEC GENERAL _ _ LIABILITY ('AMInERCI,L GENERAL LIABffTY JD:A;M$nwDE LOGGIR� � ' REMO DATE FOR CLAIMS Moe: EACR OCCURRENCE ' S OAMgl � TO <Zr�W -ZP�M� S Mm EJ9_(Myann pt�znp 8 FERSOWL. i:.:0'VIWURY CENEMLAGWREGATE PROD'JCiS- �AAfP^JPAGG S b !S VEHI0.E-IABIUW X _ x X ANYAUTO ALL OWWDAUTOS SOHECLl,EO AUTOS I MI OWJTOS NOISOWNEDAUTOS I I I COMBLNMENGE'Imrf S 1, ODD, 000 SOJIYIIJL'RYPw peOO-•) $ BO OILY IWUR'YjWr apdd'v I - -__ `PFOYEKTY DANV.G= ___I_S _.__ MEO:CAL PAYMENTS is S•ODO PERSONAL IN_NR�-F,.�O_T S UNINSURED MOTORIST S 1, ODD, 000 UNCSL 1S 11,000,000 VEHICLEPHYGICALDAMAOE DED ��PLLVEHICLES IJ SCHEDULED VEHICLES x COLLISPDR. 1,000; x H- RnIAr, ___1,000 $ee Attached Vehicle List x Aljt AL CA t!VAI.UE_ $ GARAGE LIABILITY i ANY AUTO AtrrG9HlYi J�1 \yi2o@IiT_� ICT H[?T "AUTO OWY: AGGRFGATE FXCESS LIABILITY UMBREIJAFORM TIP IR TPIAN UWFEL FORM RETRO DATE FORC MIG AMIDE: r�110_LCURREDYE__. _ _� E SELF -IN P R f. N I WORKERS UO NSATION AND EMPLDYER'S LIABILITY i 1 Y,y $j�'UPORL',U .I EL-EACHACCIDENT f EL. DISPJ,SE- FA'c1.�LOYEE I� 5 EL DI$EA$ - I R __ I SPECIAL Miscellaneous Tools Limit per Item $2,000 Limit Any One CONDRIONSIOccurrence 510,000 - $TOO Deductible ACV D'T ER MVERAG's FEES TAx�S_ -- -- - E$nMVEO TOTAL FRFT!IUM 8 MORTGAGEE r- ADDRIONAL tiJPFO LOAN tl AUTHORIZED REPRESENTATIVE Victoria CDdisDoti, CISR Page 1 of ® ACORD CORPORATION 1993-2007. Al rights reserved. ACORD 75 (2007107) The ACORD name and logo are registered marks of ACORD 11:44 949 429 6614 94% P.03 Jar 241311:33a M.U,S I. 949- 429 -66'4 p./ CONDITIONS This Company binds the kind(s) of insurance stipulated on the reverse side. The Insurance is supjact to tae terms, conditions and limitations of the policy(ies) in current use by the Company. This binder may be cancelled by the Insured by surrender of this binder a by written notice to the Company stating when cancellation will be effective. This binder may be cancelled by the Company by notice to the Insured In accordance with the polity conditions. This binder is cancelled when replaced by a police If th s binder is rot replaced by a policy, tie Company is entitled to charge a premium for the binder according to the Rules and Rates in use by the Company. Applicable in California When this form is used to provide insurance in the amount of one million dollars ($1,ODD,0001 or more, the fide of the form is changed from 'Insurance Binclaii "Cover Note ". Applicable In Colorado Ii respect to binders issued to ranter of residential premises, hone owners, condo unit owners and mobile home owners, the insurer has thirty (30) tusiness days, commencing from the effective date of coverage, to evaluate the issuance or the Insurance policy. Applicable in Delaware The mortgagee or Obligee of any mortgage or other instrument given for the purpose of creating a lien on real property shall accept as evidence of insurance a written binder issued by an authorized insurer or its agent if the binder includes or is accompanied by. the name and address of the borrower, the name and address of the lender as toss payee; a description of the Insured real property; a provision that the binder may not be canceled within the tens of the binder unless the lender and the insured borramer receive written notice of the cancel- lation at least ten (10) days prier to the cancellation; except in the case of a renewal of a policy subsequent to the closing of the loan, a paid receipt of the fair amount of the applicable premium, and the amount of insurance :overage. Chai 21 Tide 25 Paragraph 2119 Applicable in Florida Except for Auto Insurance coverage, no notice of cancellation or norrenewe of a binder is regaircd unless the duration of the binder exceeds 60 days. For auto insurance, the Insurer must give 5 days prior nonce, unless the binder is replaced by a policy or another binder in the same company. Applicable in Nevada Any person who refuses to accept a binder which provides coverage of less than $1,000,000.00 when proof is required: (A) Shaf be fined not more than $500.OD, and (B) is liable to the party presenting the binder as proof of insurance for actual damages sustained therefrom. Applicable in the Virgin Islands This binder is effective for only rinety (90) days. Within thirty (30) days cf receipt of this binder, you should request an insurance policy or certificate (if applicable) from your agent and/or insurance company. AGUKn rs (zae7lo11 Page 2 of 2 JnH -24 -20113 11;44 949 429 0614 91:: P.04 Jan 24 13 11:34a M.U.S.I. 949 - 429 -6614 p.5 Municipal Underground Services, Inc. Suppl ement to Binder # 612041703458 - 04/17/2012 Minn Rick Manaaem.nt T JAH- 24 -2L13 11:45 949 429 6614 94% P.05 Vehicle List Make/Model Year VIN Coverage Deductible 1991 Internatio /4000 Comprehensive 1,000 1HTSDNHR7MH325848 Collision 1,000 1995 Ford /LN800D Comprehensive 1,000 1FDYR82E8SVA76177 Collision 1,000 2002 GMC /Savana Comprehensive 1,000 1GTGG25R721151251 Collision 1,000 2007 Ford /F550 SD Comprehensive 1,000 1FDAF56P47ES45068 Collision 1,000 2004 Chevrolet /Express Ca Comprehensive 1,000 1GCHG39U941144412 Collision 1,000 2002 Sterling /L7500 Comprehensive 1,000 2FZAATAK62A173129 Collision 1,000 JAH- 24 -2L13 11:45 949 429 6614 94% P.05