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Insurance - Professional Pipe Service - 2016-01-28(HOFFM63) A� a CERTIFICATE OF LIABILITY INSURANCE DATE (MMIDEVYYYY) E/26/2016 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 The Graham CompanyNAME: CONTACT Joe Holden PHONE 215-701-5225 AC o: 215-933-3988 The Graham Building One Penn Square West 25th Floor Philadelphia, PA 19102 aDD EMAIL Ess: Holden Unit rahamce.com INSURERIS) AFFORDING COVERAGE NAIC p 12/31/2016UM INSURER A: First Mercury Insurance Company 10657 www.grahamco.com INSURED Hoffman Southwest Corp. Pi dba Professioionalal Pipe Service 23311 Madero Street INSURER B: Zurich American Insurance Company 16535 INSURER C : Endurance Risk Solutions Assurance Co. 43630 NSURER D: Mission Viejo CA 92691 INSURER E: INSURER F: B COVERAGES CERTIFICATE NUMBER: 28323825 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. CTR TYPE OF INSURANCE ADDL SUBR POLICY NUMBER MMIDDY POLICY YIVYW LIMITS COMMERCIAL GENERAL LIABILITY CLAIMS -MADE � OCCUR WAGGL000006027901 12/31/2015 12/31/2016UM RRENCE $ 1,000,000 ToRENTED Ea accurrence $ 100,000 ny one parson) $ 10,000 ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: POLICY ✓� jE�T LOC OTHER: GREGATE $ 2,000,000 -COMP/OP AGG $ 2,000,000 $ B AUTOMOBILE LIABILITY ANYAUTO ALLOWNED SCHEDULED AUTOS AUTOS NON -OWNED HIREDAUTOS AUTOS BAP 017954300 7/13/2015 7/13/2016 CEOMBINEDaccideISINGLE LIMIT $ 2,000,00 BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ PROPERTY DAMAGE $ Per accitlen $ C UMBRELLA LIAB EXCESS LIAB �/ OCCUR CLAIMS -MADE EXCl0004357202 12/31/2015 12/31/2016 EACH OCCURRENCE $ 10000000 AGGREGATE $ 10,000,000 DED I I RETENTION$ $ B WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y/N ANY PROPRIETOMPARTNEWEXECUTIVE OFFICEWMEMBER EXCLUDED? ❑N (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below NIA WC 017954500 7/13/2015 7/13/2016�/ PER STATurE ER E.L. EACH ACCIDENT $ 1,000,000 E.L. DISEASE - EA EMPLOYE1 $ 1,000,000 E.L. DISEASE -POLICY LIMIT IS 1,000,000 17 DESCRIPTION OF OPERATIONS LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached If more space is required) See Additional Remarks Schedule CERTIFICATE HOLDER CANCELLATION TCOSTA MESA SANITARY DISTRICT �/a �' /n SCOTT CARROLL / ly 628 WEST 19TH STREET 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 CA 92627 AUTHORIZED REPRESENTATIVE 2 William A. Graham IV ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25 (2014/01) The ACORD name and logo are registered marks of ACORD 28323825 1 HSWHOLD-01 115/16 GL AU XS WC I Charles Brennan 1 1/28/2016 9:23;19 AM (EST) I Page 1 of 3 AGENCY CUSTOMER ID: HSWHOLD-01 LOC #: A ADDITIONAL REMARKS SCHEDULE Page —Of AGENCY NAMED INSURED The Graham Company SIDE Prof ssiional Pipe Service 23311 Madero Street Mission Viejo CA 92691 POLICY NUMBER CARRIER NAIC CODE EFFECTIVE DATE: THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, HOLDER: COSTA MESA SANITARY DISTRICT SCOTT CARROLL ADDRESS: 628 WEST 19TH STREET COSTA MESA CA 92627 RE: CLOSED CIRCUIT TELEVISING (CCTV) SERVICES - RFP 02-15 COSTA MESA SANITARY DISTRICT, its directors, officials, officers, employees, agents, and volunteers are additional insureds on the above General Liability policy if required by written contract. Coverage provided to the additional insureds shall apply on a Primary / Non -Contributory Basis on the above General Liability policy if required by written contract. Prior to loss, and if required by written contract, Waiver of Subrogation is provided on Workers Compensation Policy for work performed under contract if permissible by state law. Should any of the above described policies be cancelled before the expiration date thereof, The Graham Company will endeavor to mail 30 days written notice to the certificate holder, but failure to do so shall impose no obligation or liability of any kind upon The Graham Company, its agents or representatives. 101 (2008/01 2008 ACORD CORPORATION. All riahts reserved The ACORD name and logo are registered marks of ACORD 28323825 1 HSWHOLD-01 1 15/16 GL AU XS WC I Charles Brennan 1 1/20/2016 9:23:19 AM (EST) I Page 2 of 3 ADDENDUM 28323825 1 HSWHOLU-01 115/16 UL AU %5 'WC I Charles Brennan 11/28/2036 9:23:19 AM (85'L) I Page 3 of 3