Insurance Auto-Municipal Underground-2014-04-28AJ YnGn
CERTIFICATE OF
LIABILITY INSURANCE
DATE(MM00 /YYYY)
ADDL
INSR
ili
04/28/2014
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS U C I I 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 ISSIjIPRNJU fEVMj UTHORIZED
REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER.
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IMPORTANT: if the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If I.�ct to
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the terms and conditions of the policy, certain policies may require an endorsement. A statement on this c he
certificate holder in lieu of such endomement(s).
PRODUCER
Orion Risk Management Insurance Services, Inc.
Ca. Lic. #OD28764
2280 Wardlow Circle, Suite 250
Corona, CA 92880
$
CONTACT
NAME:
a"c °NqE :t:951.736.9477 ac rvq951.736.9478
E -MAIL
ADDRESS:
CPROOUCER 00001641
UST MER 10 .
INSURER(S) AFFORDING COVERAGE
NAIC#
INSURED
INSURERA: Employers Mutual Casualty Co.
$
Municipal Underground Services, Inc.
PRODUCTS- COMP /OP AGO
INSURER B:
28511 Breckenridge Drive
A
INSURER C:
LIABILITY
ANYAUTO
ALL OWNED AUTOS
SCHEDULED AUTOS
HIRED AUTOS
NON -OWNEDAITTOS
Laguna Niguel, CA 92677
INSURER D:
0411812014
INSURER E:
COMBINED SINGLE LIMIT
(Ea accident)
$ 1, 000, OD
BODILY INJURY (Per Person)
INSURER F:
BODILY INJURY (Per accident)
$
PROPERTY DAMAGE
(Per accident)
COVERAGES CERTIFICATE NUMBER: 14 -15 Auto 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
ADDL
INSR
SUBR
ME)
POLICY NUMBER
POLICY BEE
MMIDO
POLICY EXP
MM1DD/YYYY
LIMITS
GENERAL LIABILITY
COMMERCIAL GENERAL LIABILITY
CLAIMS -MADE OCCUR
EACH OCCURRENCE
$
RENTED
PREMISES Ea oaurrenoe
$
MED EXP(Any one person)
$
PERSONALBADVINJURY
$
GENERAL AGGREGATE
$
GENT AGGREGATE LIMIT APPLIES PER
POLICY PRO- LOC
JECT
PRODUCTS- COMP /OP AGO
$
$
A
AUTOMOBILE
X
X
X
LIABILITY
ANYAUTO
ALL OWNED AUTOS
SCHEDULED AUTOS
HIRED AUTOS
NON -OWNEDAITTOS
4E43249
0411812014
0411812015
COMBINED SINGLE LIMIT
(Ea accident)
$ 1, 000, OD
BODILY INJURY (Per Person)
$
BODILY INJURY (Per accident)
$
PROPERTY DAMAGE
(Per accident)
$
$
$
UMBRELLA LIAB
EXCESS ILIAD
OCCUR
CLAIMS -MADE
EACH OCCURRENCE
$
AGGREGATE
$
DEDUCTIBLE
RETENTION $
$
$
WORKERS COMPENSATION
YIN
ANY PROPRIETORIPARTNER/EXECUTIVE
OFFICER/MEMBER EXCLUDED?
(Mandatory in NH)
If yes, describe under
DESCRIPTION OF OPERATIONS below
NIA
WC S A]
TORY LIMITS ER
E.L. EACH ACCIDENT
$
E.L. DISEASE - EA EMPLOYE
$
L.L. DISEASE - POLICY LIMIT
$
DESCRIPTION OF OPERATIONS /LOCATIONS /VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required)
vidence of insurance
CERTIFICATE HOLDER CANCELLATION
Costa Mesa Sanitary DistrictV �j�
�
628 W. 19th St. t� "!�
Costa Mesa, CA 92627
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
AUTHORIZED REPRESENTATIVE LX
ACORD 25 (2009/09) The ACORD name and logo are registered marks of ACORD