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Insurance - OC Waste & Recyling - Clean Harbors Inc. 2016-08-22CLEAHAR-01 BURRAU ,4coR0 CERTIFICATE OF LIABILITY INSURANCE DATE122/2016 /122/201622/2016 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(les) 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 Massachusetts, Inc. c/o 26 Century Blvd P.O. Box 305191 CONTACT NAME: Willis Towers Watson Certificate Center PHONE (877) 945-7378 n/c Ne; (888) 467-2378 No Est: E-MAIL certificates@willis.com Nashville, TN 37230.5191 INSURER(S)AFFORDING COVERAGE NAICp INSURER A:ACE American Insurance Company 22667 INSURED INSURER B: American Guarantee and Liability Insurance CompanY 26247 INSURER C: Indemnity Insurance Company of North America 43575 Clean Harbors, Inc. INSURER D: 42 Longwater Drive Norwell, MA 02061 INSURER E: INSURER F: 11101/2016 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 CONTRACTOR 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 INSD MID POLICY NUMBER POLICY EFF MMIDD/YYYY POLICY EXP MM/DDIYYYY LIMITS A X COMMERCIAL GENERAL LIABILITYEACH OCCURRENCE $ 2,000,00 CLAIMS -MADE I X1 OCCUR X HDOG2740067A 1110112015 11101/2016 PREMISES Eacaurrence $ 500,00 X XCU MED EXP (My one person) $ 5,00 X I Contractual PERSONAL&ADV INJURY $ 2,000,00 GEWL AGGREGATE LIMIT APPLIES PER GENERAL AGGREGATE $ 4,000,00 POLICY N JE ' F-1 LOC PRODUCTS - COMP/OP AGG $ 4,000,00 $ OTHER: AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ 5,000,00 Ea accident) BODILY INJURY (Per person) $ A X ANY AUTO X ISAH08860889 1110112015 11/0112016 X ALL OWNED SCHEDULED AUTOS AUTOS BODILY INJURY (Per accident) $ XX NON -OWNED HIRED AUTOS AUTOS PROPERTY DAMAGE $ Per accident) X MCS -90 $ UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 10,000,006 B 1X EXCESS LIAB CLAIMS -MADE AUC 4275262-11 11101/2015 11/0112016 AGGREGATE $ 10,000,000 OED I X I RETENTION$ 0 $ C WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANY PROPRIETOR/PARTNERIEXECUTIVE YIN OFFICERIMEMBER EXCLUDEDP (Mandatory In NH) LRC48592739(ADS) 11101/2015 11/01/2016 X P OTH- STATUTE ER E.L. EACH ACCIDENT $ 2,000,00 E.L. DISEASE - EA EMPLOYE $ 2,000,00 N yes, Rdescnba under DE SCRIPTION OF OPERATIONS below [11 E.L. DISEASE -POLICY LIMB s 2,000,00 A Work Comp 8. Emp Liab WLRC48592715 (AZ, CA, MA) 11101/2015 11/0112016 See Attached DESCRIPTION OF OPERATIONS/ LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached If more space is required) THIS CERTIFICATE VOIDS AND REPLACES THE PREVIOUSLY ISSUED CERTIFICATE DATED: 8/1612016 Scope of Work: HOUSEHOLD HAZARDOUS WASTE COLLECTION SITE Site Address: 2701 FAIRVIEW ROAD COSTA MESA, CA 92626 Certificate Holder is named as an Additional Insured for General Liability and Auto Liability, as their interests may appear if required by written contract but only with respect to liability arising out of operations of the Named Insured. 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 THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. COUNTY OF ORANGE OC WASTE AND RECYCLING AUTHORIZED REPRESENTATIVE JESUS PEREZ 300 NORTH FLOWER STREET SUITE 400 300 SANTA ANA CA 92703 ACORD 25 (2014101) @ 1988-2014 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD ADDITIONAL COVERAGE SCHEDULE COVERAGE LIMITS POLICY TYPE: Workers Compensation & Employers Per Statute Liability E.L. Each Accident $2,000,000 CARRIER: ACE American Insurance Company E.L. Disease — Each Employee $2,000,000 POLICY TERM: 11/01/2015 - 11/01/2016 E.L. Disease — Policy Limit $2,000,000 POLICY NUMBER: WLRC48592715 (AZ, CA, MAI POLICY TYPE: Contractors Pollution $10,000,000 Each Claim CARRIER: ACE American Insurance Company $10,000,000 All Claims POLICY TERM: 11/0112015 -11/01/2016 $250,000 SIR POLICY NUMBER: COO G27416603 001 POLICY TYPE: Professional Liability $10,000,000 Each Claim CARRIER: ACE American Insurance Company $10,000,000 All Claims POLICY TERM: 11/01/2015 -11/01/2016 $250,000 SIR POLICY NUMBER: COO G27416603 001 im ace usa LEAD SHEET FOR: WILLIS OF MASSACHUSETTS INC RUN DATE: 08/19/2016 POLICY NUMBER: HDO G2740067A ID: Z02KANK1 RUN BY: ACEINA\K4KAND PAGES OF THIS COPY: 0004 INSURED'S NAME Clean Harbors, Inc. POLICY NUMBER: HDO G2740067A o. ace group Policyholder Notice Commercial Lines Deregulation New York NOTICE: THESE POLICY FORMS AND THE APPLICABLE RATES ARE EXEMPT FROM THE FILING REQUIREMENTS OF THE NEW YORK INSURANCE LAW AND REGULATIONS. HOWEVER, THE FORMS AND RATES MUST MEET THE MINIMUM STANDARDS OF THE NEW YORK INSURANCE LAW AND REGULATIONS. CLASS CODE 2-14057 ALL -23445b (07/13) Page 1 of 1 GENERALENDORSEMENT Named Insured Endorsement Number Clean Harbors, Inc. 370 Policy Symbol Policy Number Policy Period Effective Date of Endorsement HDO G2740067A 11/01/2015 to 11/01/2016 08/16/2016 Issued By (Name of Insurance Company) ACE American Insurance Company Insert the policy number. The remainder of the Information is to be completed only when this endorsement is issued subsequent to the preparation of the policy. THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART It is agreed effective 08/16/2016 that the following endorsement is added to the policy: Endorsement #371, LD -20287 (06/06), Non -Contributory Endorsement For Additional Insureds Authorized Representative CC -3R19 (8/97) Page 1 of 1 NON-CONTRIBUTORY ENDORSEMENT FOR ADDITIONAL INSUREDS Named Insured Endorsement Number Clean Harbors, Inc. 371 Policy Symbol Policy Number Policy Period Effective Date of Endorsement HDO G2740067A 11/01/2015 to 11/01/2016 08/16/2016 Issued By (Name of Insurance Company) ACE American Insurance Company isert the policy number. The remainder of the information is to be completed only when this endorsement is issued subsequent to the preparation of the policy. THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. COMMERCIAL GENERAL LIABILITY COVERAGE Schedule Organization Additional Insured Endorsement The Costa Mesa Sanitary District, it's elected and appointed officials, agents, officers, volunteers and employees are additional Insureds. (If no information is filled in, the schedule shall read: 'AI/ persons or entities added as additional insureds through an endorsement with the term 'Additional Insured" in the title) For organizations that are listed in the Schedule above that are also an Additional Insured under an endorsement attached to this policy, the following is added to Section IVA.a: If other insurance is available to an insured we cover under any of the endorsements listed or described above (the "Additional Insured") for a loss we cover under this policy, this insurance will apply to such loss on a primary basis and we will not seek contribution from the other insurance available to the Additional Insured. Authorized Agent LD -20287 (06/06) Page 1 of 1 NOTICE TO OTHERS ENDORSEMENT - SPECIFIC PARTIES Named Insured Clean Harbors, Inc. Endorsement Number Physical Address 376 Policy Symbol Policy Number Policy Period Effective Date of Endorsement ISA HO8860889 11/01/2015 To 11/01/2016 08/16/2016 Issued By (Name of Insurance Company) ACE American Insurance Company Insert the policy number. The remainder of the information is to be completed only when this endorsement is issued subsequent to the preparation of the policy. THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. A. If we cancel the Policy prior to its expiration date by notice to you or the first Named Insured for any reason other than nonpayment of premium, we will endeavor, as set out below, to send written notice of cancellation, via such electronic or other form of notification as we determine, to the persons or organizations listed in the schedule set out below (the "Schedule"). You or your representative must provide us with both the physical and e-mail address of such persons or organizations, and we will utilize such e-mail address or physical address that you or your representative provided to us on such Schedule. B. We will endeavor to send or deliver such notice to the e-mail address or physical address corresponding to each person or organization indicated in the Schedule at least 30 days prior to the cancellation date applicable to the Policy. C. The notice referenced in this endorsement is intended only to be a courtesy notification to the person(s) or organization(s) named in the Schedule in the event of a pending cancellation of coverage. We have no legal obligation of any kind to any such person(s) or organization(s). Our failure to provide advance notification of cancellation to the person(s) or organization(s) shown in the Schedule shall impose no obligation or liability of any kind upon us, our agents or representatives, will not extend any Policy cancellation date and will not negate any cancellation of the Policy. D. We are not responsible for verifying any information provided to us in any Schedule, nor are we responsible for any incorrect information that you or your representative provide to us. If you or your representative does not provide us with the information necessary to complete the Schedule, we have no responsibility for taking any action under this endorsement. In addition, if neither you nor your representative provides us with e-mail and physical address information with respect to a particular person or organization, then we shall have no responsibility for taking action with regard to such person or entity under this endorsement. E. We may arrange with your representative to send such notice in the event of any such cancellation. F. You will cooperate with us in providing, or in causing your representative to provide, the e-mail address and physical address of the persons or organizations listed in the Schedule. G. This endorsement does not apply in the event that you cancel the Policy. SCHEDULE Name of Certificate Holder E -Mail Address Physical Address The Costa Mesa Sanitary District 628 W. 191^ Street Costa Mesa, CA 92627 ALL -32688 (01/11) Page 1 of 2 ig ace usa LEAD SHEET FOR: WILLIS OF MASSACHUSETTS INC RUN DATE: 08/18/2016 POLICY NUMBER: ISA H08860889 ID: Z02KANK1 RUN BY: ACEINA\K4KAND PAGES OF THIS COPY: 0007 INSURED'S NAME Clean Harbors, Inc. Wffl I [ova 0 ill A 1.1 A "M RIM1Z:I IYiII8!1 lot ace group Policyholder Notice Commercial Lines Deregulation New York NOTICE: THESE POLICY FORMS AND THE APPLICABLE RATES ARE EXEMPT FROM THE FILING REQUIREMENTS OF THE NEW YORK INSURANCE LAW AND REGULATIONS. HOWEVER, THE FORMS AND RATES MUST MEET THE MINIMUM STANDARDS OF THE NEW YORK INSURANCE LAW AND REGULATIONS. CLASS CODE 2-14057 ALL -23445b (07/13) Page 1 of 1 35 GENERAL PURPOSE ENDORSEMENT POLICY NUMBER: ISA H08860889 PRODUCER NUMBER: 220256 ITEM ONE- POLICY INFORMATION Named Insured: Clean Harbors, Inc. Address: P.O. Box 9149 Norwell MA 02061 Policy Period: 11/01/2015 to 1 1101 /2 01 6 This Endorsement Effective: 08/16/2016 12:01 a.m. standard time at the named insured's address stated above. In -Term Policy Change Number: 373 ENDORSEMENT SUMMARY: It is agreed effective 08/16/2016 that the following endorsements are added to the policy: Endorsement #374, DA-9U74b (06/14), Additional Insured - Designated Persons Or Organizations Endorsement #375, DA -21886b (06/14), Non -Contributory Endorsement For Additional Insureds Endorsement #376, ALL -32688 (01/11), Notice To Others Endorsement — Specific Parties 5: AUTHORIZED REPRESENTATIVE DA -31<66 (08/11) Page 1 of 1 ADDITIONAL INSURED — DESIGNATED PERSONS OR ORGANIZATIONS Named Insured Endorsement Number Clean Harbors, Inc. 374 Policy Symbol Policy Number Policy Period Effective Date of Endorsement ISA 408860889 11/01/2015 to 11/01/2016 08/16/2016 Issued By (Name of Insurance Company) ACE American Insurance Company Insert the policy number. The remainder of the information is to be completed only when this endorsement is issued subsequent to the preparation of the policy. THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. This endorsement modifies insurance provided under the following: BUSINESS AUTO COVERAGE FORM AUTO DEALERS COVERAGE FORM MOTOR CARRIER COVERAGE FORM EXCESS BUSINESS AUTO COVERAGE FORM EXCESS TRUCKERS COVERAGE FORM Additional Insured(s): The Costa Mesa Sanitary District, it's elected and appointed officials, agents, officers, volunteers and employees are additional insureds_ A. For a covered "auto," Who Is Insured is amended to include as an "insured;' the persons or organizations named in this endorsement. However, these persons or organizations are an "insured" only for "bodily injury" or "property damage" resulting from acts or omissions of: 1. You. 2. Any of your "employees" or agents. 3. Any person operating a covered "auto' with permission from you, any of your "employees" or agents. B. The persons or organizations named in this endorsement are not liable for payment of your premium. Authorized Representative DA-91J74b (06/14) Page 1 of t NON-CONTRIBUTORY ENDORSEMENT FOR ADDITIONAL INSUREDS Named Insured Clean Harbors, Inc. Endorsement Number 375 Policy Symbol Policy Number Policy Period Effective Date of Endorsement ISA HO8860889 11/01/2015 To 11/01/2016 08/16/2016 Issued By (Name of Insurance Company) ACE American Insurance Company Insert the policy number. The remainder of the information is to be completed only when this endorsement is issued subsequent to the preparation of the policy. THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. BUSINESS AUTO COVERAGE FORM MOTOR CARRIER COVERAGE FORM AUTO DEALERS COVERAGE FORM Schedule Organization Additional Insured Endorsement The Costa Mesa Sanitary District, it's elected and appointed officials, agents, officers, volunteers and employees are additional insureds. (If no information is filled in, the schedule shall read: 'All persons or entities added as additional insureds through an endorsement with the term Additional Insured" m the title) For organizations that are listed in the Schedule above that are also an Additional Insured under an endorsement attached to this policy, the following is added to the Other Insurance Condition under General Conditions: If other insurance is available to an insured we cover under any of the endorsements listed or described above (the "Additional Insured") for a loss we cover under this policy, this insurance will apply to such loss on a primary basis and we will not seek contribution from the other insurance available to the Additional Insured. Authorized Representative DA -21886b (06/14) Page 1 of 1 Name of Certificate Holder I E -Mail Address I Phvsical Address All other terms and conditions of this Policy remain unchanged. Authorized Representative ALL -32688 (01/11) Page 2 of 2