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Insurance - Charles King Co. Inc. - 2015-06-01CHAKIN-001 LODE 144c"j? o CERTIFICATE OF LIABILITY INSURANCE DAT6/11/2 DIYYYY) 6/1/2015 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 (888) 825-4322 Bowermaster & Associates P.O. Box 6026 10805 Holder Street - Suite 350 RECEIVED Cypress, CA 90630 CONTACT Denise Lopez _ PHONE 714-733-6200 219 FA% ac No Ext: AIC No: 714.252-8253 E-MAIL ADDRESS: diopez@bowermaster.com INSURER(S) AFFORDING COVERAGE NAIC M INSURER A: National Fire Insurance of Hartford ,20478 ���"� INSURED Charles King Company, Inc. iU 2841 Gardena Avenue Signal Hill, CA 90755 COSTA MESA SANITARY DISTRICT INSURER B: Continental Casualty Co. INSURER C: Torus National Insurance Company INSURER D: AIG Specialty Insurance Company INSURER E: First Mercury Insurance 10657 INSURER F: COVERAGES CERTIFICATE NUMBER: 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 INSD UBR WVD POLICY NUMBER POLICY EFF MMIDD'YYYY POLICY EXP MM/DDIYYYY LIMITS A X I COMMERCIAL GENERAL LIABILITY CLAIMS -MADE IX OCCUR Y Y 4034952911 3/30/2015 3/30/2016 EACH OCCURRENCE $ 1,000,000 DAMAGE TREN PREMISES Ea occurrence $ 100,000 X Deductible; $5,000 MED EXP (Any one person) $ 5,000 X PropertyDamage/Subsidence PERSONALBADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 POLICY C JECT [::] LOC PRODUCTS -COMPI AGG $ 2,000,000 $ OTHER: AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ 1,099,096 Ea accident BODILY INJURY (Per person) $ BX ANY AUTO N Y 5091114974 3130/2015 3/3012016 ALL OWNED SCHEDULED AUTOS AUTOS - BODILY INJURY (Per accident) $ X: X NON -OWNED HIRED AUTOS AUTOS PROPERTY DAMAGE $ Per accident $ X UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 16,000,000 AGGREGATE $ 10,000,000 A E%CESS LIAB CLAIMS -MADE N N 5091114988 3/3012015 3/30/2016 DED X i RETENTION$ 10,000 $ C WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANY PROPRIETOR/PARTNERIEXECUTIVE YIN OFFICERIMEMBER EXCLUDED? (Mandatory in NH) NIA Y 710150030 6/212915 6/2/2016 X PER OTH- STATUTE ER E.L. EACH ACCIDENT $ 1,699,999EE E.L. DISEASE - EA EMPLOY1,000,000 $ If yes, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE -POLICY LIMIT $ 1,666,996 D Pollution Liability N N CPL3850939 3130/2015 3/30/2016 Ded: $10,000 $5,000,000 E Excess Liability N N CAEX000005309701 3130/2015 3/30/2016 $8,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) Project No. 192 System Wide Sewer Reconstruction Phase II Costa Mesa Sanitary District, its employees and agents are Additional Insured with respects to General Liability per attached endorsement form G140331 D, Primary and Non -Contributory included. Waiver of Subrogation applies to WorkComp per attached endorsement form WC040306. Waiver of Subrogation applies to Auto Liability per formCNA63359XX and General Liability perform G18652J. Cancellation policy forms attached IL00171198 and IL02700907. CERTIFICATE HOLDER CANCELLATION ACORD 25 (2014101) © 1988-2014 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Costa Mesa Sanitary District/ 628 W. 19th Street _0 1/�J/i� THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Costa Mesa, CA 92627- o/ I AUTHORIZED REPRESENTATIVE —y ACORD 25 (2014101) © 1988-2014 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD CHAKIN-001 LODE CERTIFICATE OF LIABILITY INSURANCE DAT6/11/2 DYYYY) 6/1/2015 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 (888) 825-4322 Bowermaster &AssociatesRECEIVED P.O. Box 6026 10505 Holder Street - Suite 350 NAMEACT Denise Lopez a0"N E.t:714-733-6200 219 ac No : 714-252-8253 E-MAIL ADDRESS: diopez@bowermaster.com INSURER(S) AFFORDING COVERAGE NAIC N Cypress, CA 90630 JUN 0 3 209- INSURER A: National Fire Insurance of Hartford 20478 313012015 INSURED Charles King Company, Inc. Ci INSURER B: Continental Casualty Co. OHMAGE( N ED PREMISESSEa occurrence) $ 100,000 INSURER C: Torus National Insurance Company Deductible;$5,000 2841 Gardena Avenue Signal Hill, CA 90755 INSURER D: AIG Specialty Insurance Company INSURERE -First Mercury Insurance 10657 PropertyDamage/Subsidence INSURER F: X COVERAGES CERTIFICATE NUMBER: 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 rypE OF INSURANCE LTR ADDL INSD BR WVD POLICY NUMBER POLICYEFF MMIDDIYYYY) I POLICYEXP i 1MMIDDIYYYY1 LIMITS A X - COMMERCIAL GENERAL LIABILITY CLAIMS -MADE � OCCUR Y N 4034952911 313012015 3/30/2016 EACH OCCURRENCE $ 1,000,000 OHMAGE( N ED PREMISESSEa occurrence) $ 100,000 X Deductible;$5,000 MED EXP (Any one person) $ 5,000 PropertyDamage/Subsidence PERSONAL &ADV INJURY $ 1,000,000 X AGGREGATE LIMIT APPLIES PER: POLICY I JE� D LOC GENERAL AGGREGATE $ 2,000,000 GEN'L PRODUCTS - COMP/OP AGG $ 2,000,000 $ OTHER: AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea accident $ 1,000,000 B X ANY AUTO N N 5091114974 3/30/2015 313012016 BODILY INJURY (Per person) $ ALL OWNED SCHEDULED AUTOS AUTOS BODILY INJURY Per accident $ ( ) X HIRED AUTOS X NON -OWNED AUTOS PROPERTY DAMAGE $ Per accitlart XUMBRELLA LIAB X OCCUR I EACH OCCURRENCE $ 10,000,000 A EXCESS LIAB CLAIMS -MADE N N 1,5091114966 3/30/2015 3/30/2016 AGGREGATE $ 10,000,000 I DEO X RETENTION$ 10,000 $ C WORKERS COMPENSATIONPER AND EMPLOYERS' LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE Y I N OFEXCLUDED? ❑NIA N T10150030 6/2/2015 6/2/2016 DTH - X STATUTE ER E.L. EACH ACCIDENT $ 11000,000 E.L. DISEASE - EA EMPLOYEE;$ 1,000,000 (Mandatory in Ni If yes, describe under E.L. DISEASE- POLICY LIMIT $ 1,000,000 DESCRIPTION OF OPERATIONS below D Pollution Liability N N CPL3850939 3/30/2015 313012016 Ded: $10,000 $5,000,000 E Excess Liability N N CAEX000005309701 3/30/2015 3/3012016 $8,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) Costa Mesa Sanitary District is an Additional Insured with respects to General Liability per attached endorsement form G140331D. Costa Mesa Sanitary District 628 W. 19th Street Costa Mesa, CA 92627 - L"i 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 ©1988.2014 ACORD CORPORATION. All riahts reserved ACORD 25 (2014101) The ACORD name and logo are registered marks of ACORD WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 0403 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 _`% of the California workers' compensation premium otherwise due on such remuneration. Schedule Person or Organization Job Description WHERE YOU ARE REQUIRED BY WRITTEN CONTRACT TO OBTAIN THIS AGREEMENT FROM US, PROVIDED THE CONTRACT IS SIGNED AND DATED PRIOR TO THE DATE OF LOSS TO WHICH THIS WAIVER APPLIES. IN NO INSTANCE SHALL THE PROVISIONS AFFORDED BY THIS ENDORSEMENT BENEFIT ANY COMPANY OPERATING AIRCRAFT FOR HIRE. *The premium charge for this endorsement shall be 2% of the premium developed in the State of California, but not less than $500 policy minimum premium. 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 06/02/15 Policy No. T10150030 Insured Charles King Company, Inc. Insurance Company Torus National Insurance Company Countersigned By WC 04 03 06 (Ed. 4-84) 01998 by the Workers' Compensation Insurance Rating Bureau of California. All rights reserved. Endorsement No. 10 Policy Effective Date 06/02/15 The enclosed Certificate issued to your company is for the renewal of COMMERCIAL WORKERS COMPENSATION ONLY. The Certificates and Endorsements that you received reflecting the Liability coverages with effective dates of 3/30/15 — 3/30/16 for Charles King Company, Inc., are still active and valid. For questions concerning the enclosed document, please contact: Denise J. Lopez, CISR Bowermaster & Associates (714) 733-6219 Direct Line dlopez(aD-bowermaster.com THANK YOU.