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Insurance - Mike Kilbride, LTD 2016-11-03A� O" CERTIFICATE OF LIABILITY INSURANCE DATE (MMIDD/YYYY) 11/03/2016 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 Phone: (760)937-3626 Fax (760)837-3698 CONTACT M. L. Adams Insurance Services M. L. ADAMS INSURANCE SERVICES NAME' _ 42-280 BEACON HILL, SUITE D-7 INC.N Exe (760) 837_-3626 - - I(a Nm. (760) 837-3898 EMAIL WWW.mladamsins.com PALM DESERT CA 92211-5168 ADDRESS: INSURER(S) AFFORDING COVERAGE NAIC# MIKE KILBRIDE, LTD. COAST WATER AND POWER P.O. BOX 3341 NEWPORT BEACH CA 92659 Agency LicAl 0609232 1 INSURER Colony Insurance Co' INSURER B State Compensation Insurance Fund INSURER D'. INSURER INSURER F Insurance Cc/ COVERAGES CERTIFICATE NUMRFR- 79599 REVICInm NI IMRFR. THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO 'HE 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 ADDLE INSD SUER MD POLICY NUMBER POLICY EFF IMM/DEVYYYY) 10/30/16 POLICY EXP IMMIDDYY M' LIMITS $ 1,000,000 J� X COMMERCIAL GENERAL LIABILITY X X 103GLOO15876-00 10/30/17 EACH OCCURRENCE CLAIMS -MADE AlOCCUR DAMAGE TO RENTED- $ 100,660 PREMISES Fe oceurence) MED. EXP (Any one person) _ S 5,000 PERSONAL& ADVINJURV $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER GENERALAGGREGATE $ 2,000,000 POLICY [X] PRO- a LOC PRODUCTS - COMP/OP AGG $ 2,000,000 JECT OTHER: IS AUTOMOBILE LIABILITY COMBINED LE LIMIT (EaW aaent)enp $ ANY AUTO BODILY INJURY (Per person) $ AO BODILY BODILY INJURY(Per accident) AUTOS AUTOSSCHED $ HIREDAUTOS NON -OWNED PROPERins, GE — $ AUTOS (per ecciaenp C UMBRELLA LAB X OCCUR XS3306768-02 10/30/16 10/30/17 EACH OCCURRENCE $ 2,000,000 EXCESS LWB CLAIMS -MADE AGGREGATE $ 2,000,000 DED I RETENTION$ It B WORKERS COMPENSATION X 9087110-16 10/01/16 10/01/17 XSTATUTE 1,000,000 AND EMPLOYERS' LIABILITY ER ANY PROPRIETORIPARTNEWEXECUTIVE YIN E. L. EACH ACCIDENT $ 1,000,000 OFFTCERft EXCLUDED? NIA E.L. DISEASE -FA EMPLOYEE $ INCLUDED In NH)NHI (Merltlatogry in Dyes,IPTI Nun er DESCRIPTION OF OPERATIONS below E.L. DISEASE-P000Y LIMIT $ INCLUDED DESCRIPTION OF OPERATIONS (LOCATIONS /VEHICLES (AGO RD 701, Additional Remarks Schedule, may be attached if more space is required) RE: ALL OPERATIONS THE COSTA MESA SANITARY DISTRICT, IT'S ELECTED AND APPOINTED OFFICIALS, AGENTS, OFFICERS AND EMPLOYEES ARE NAMED AS ADDITIONAL INSUREDS PER FORM CG 20 12 04 13 ATTACHED. PRIMARY WORDING PER FORM CG 20 01 0413 ATTACHED. 30 DAYS NOTICE OF CANCELLATION PER FORM ATTACHED. liCRl lr RiXIC nULLICR UANUMLLA I IVIV SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE COSTA MESA SANITARY DISTRICT _,/y{, `� /Il THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 628 W. 19TH ST. 1x/�I(+') (/ ACCORDANCE WITH THE POLICY PROVISIONS. COSTA MESA, CA 92627 - — — --_- _ -- _-- -- -- AUTHORIZED REPRESENTATIVE Attention: Michael L. (Mike) Adams :ORD 25 (2014/01) © 1988-2014 ACORD CORPORATION. All rights reserved. I ne AGUKU name and logo are registered marKS OT AGUKU 103 GL 0015876-00 POLICY NUMBER: 103 GL 0015876-00 COMMERCIAL GENERAL LIABILITY CG 20 12 04 13 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - STATE OR GOVERNMENTAL AGENCY OR SUBDIVISION OR POLITICAL SUBDIVISION - PERMITS OR AUTHORIZATIONS This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE State Or Governmental Agency Or Subdivision Or Political Subdivision: COSTA MESA SANITARY DISTRICT, ITS ELECTED AND APPOINTED OFFICIALS AND EMPLOYEES 628 W 19TH AVE COSTA MESA, CA 92627 Information required to complete this Schedule, if not shown above, will be shown in the Declarations. A. Section 11 — Who Is An Insured is amended to include as an additional insured any state or governmental agency or subdivision or political subdivision shown in the Schedule, subject to the following provisions: 1. This insurance applies only with respect to operations performed by you or on your behalf for which the state or governmental agency or subdivision or political subdivision has issued a permit or authorization. However: a. The insurance afforded to such additional insured only applies to the extent permitted by law; and b. If coverage provided to the additional insured is required by a contract or agreement, the insurance afforded to such additional insured will not be broader than that which you are required by the contract or agreement to provide for such additional insured. 2. This insurance does not apply to: a. "Bodily injury", "property damage" or "personal and advertising injury" arising out of operations performed for the federal government, state or municipality; or b. "Bodily injury" or "property damage" included within the "products -completed operations hazard". B. With respect to the insurance afforded to these additional insureds, the following is added to Section III — Limits Of Insurance: If coverage provided to the additional insured is required by a contract or agreement, the most we will pay on behalf of the additional insured is the amount of insurance: 1. Required by the contract or agreement; or 2. Available under the applicable Limits of Insurance shown in the Declarations; whichever is less. This endorsement shall not increase the applicable Limits of Insurance shown in the Declarations. CG 20 12 04 13 0 Insurance Services Office, Inc., 2012 Page 1 of 1 103 GL 0016876-00 COMMERCIAL GENERAL LIABILITY CG 20 0104 13 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. PRIMARY AND NONCONTRIBUTORY - OTHER INSURANCE CONDITION This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE PART The following is added to the Other Insurance Condition and supersedes any provision to the contrary: Primary And Noncontributory Insurance This insurance is primary to and will not seek contribution from any other insurance available to an additional insured under your policy provided that: (1) The additional insured is a Named Insured under such other insurance: and (2) You have agreed in writing in a contract or agreement that this insurance would be primary and would not seek contribution from any other insurance available to the additional insured. CG 20 01 04 13 0 Insurance Services Office, Inc., 2012 Page 1 of 1 103 GL 0016876-00 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. NOTICE OF CANCELLATION - DESIGNATED PERSON(S) OR ORGANIZATION(S) This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE PART SCHEDULE Name of Person(s) or Organization(s): COSTA MESA SANITARY DISTRICT The Person(s) or Organization(s) listed or described in the SCHEDULE above have requested that they receive written notice of cancellation when this policy is cancelled by us. It is agreed that should this policy be cancelled before the expiration date thereof, the issuing company will endeavor to mail 30 days written notice (10 days for non-payment of premium) to the additional insured. The notification of cancellation of the policy is solely for the purpose of informing the Person(s) or Organization(s) shown in the SCHEDULE the effective date of cancellation and does not grant, alter, or extend any rights or obligations under this policy. Our failure to provide such notification will not extend any policy cancellation date nor impact or negate any cancellation of the policy. Any provision of this endorsement that is in conflict with a statute or rule is hereby amended to conform to that statute or rule. ALL OTHER TERMS AND CONDITIONS OF THE POLICY REMAIN UNCHANGED. U900-0513 Includes copyrighted material of ISO Properties, Inc., Page 1 of 1 with its permission.