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Insurance - Robotic Sewers 2017-03-13ACC>R o® CERTIFICATE OF LIABILITY INSURANCE DATE/13/201f 7yy) 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, 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 have ADDITIONAL INSURED provisions or 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 Bolton & Company 3475 E. Foothill Blvd., Suite 100 Pasadena, CA 91107 COONNTACT PHOMC,NENo EA, 626 799-7000 FAX No: 626 583-2117 E-MAIL ADDRESS: INSURERS AFFORDING COVERAGE NAIC# 000506276 INSURER A: James River Insurance Company 7 12203 www.boltonco.com 0006309 INSURED Robotic Sewer Solutions, Inc. 1111 Foothill Boulevard, Suite B INSURER B: State Compensation Insurance Fund of CA 35076 INSURER C: Samsung Fire &Marine Insurance Co. 420022 INSURER D: Torus National Insurance Company25496 La Canada, CA 9 10 11 INSURER E: INSURER F: DAMAGETORENTED PREMISES Ea occunenrs $ 50,000 COVERAGES CERTIFICATE NUMBER: 34635908 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, I TR TYPE OF INSURANCE AODL SUER POLICY NUMBER MMIDDmYY POLICY EXP LIMITS A COMMERCIAL GENERAL LIABILITY 4/ 000506276 11/22/2616 11/22/2617 EACH OCCURRENCE $ 1,000,000 CLAIMS -MADE OCCUR � ✓ DAMAGETORENTED PREMISES Ea occunenrs $ 50,000 MED EXP (Any one person) $ Excluded ,,#Proiect Aggregate ✓ Capped at $10,000,000 PERSONAL &ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLI ES PER: GENERAL AGGREGATE $ 2,000,000 - POLICY0 PET 1:1 LOC PRODUCTS-COMP/OP AGG $ 2,000,000 $ OTHER: C AUTOMOBILE LIABILITY CPP006406404 8/1/2016 6/1/2017 EDacccldentSINGLE LIMIT $ 1,000000 BODILY INJURY (Per person) $ ✓ ANYAUTO OWNED SCHEDULED AUTOS ONLY AUTOS BODILY INJURY (Per accident) $ HIRED NON -OWNED AUTOS ONLY AUTOS ONLY PROPERTY DAMAGE $ Per accident D UMBRELLALIAB �/ OCCUR 87446H163ALI 11/22/2016 11/22/2017 EACH OCCURRENCE $ 4000000 AGGREGATE $ 4,000,000 ✓ EXCESS LIAB CLAIMS -MADE DED ✓ RETENTION$0 $ B WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANYPROPRIETOWPARTNERIEXECUTIVE YIN OFFICERIMEMBER EXCLUDED? ❑Y NIA ✓ 198026416 11/22/2016 11/22/2017 ✓ STATUTE ETH E.L. EACH ACCIDENT $ $1,000,000 E.L. DISEASE - EA EMPLOYEE $ $1000000 (Mandatory in NH) - If yes, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE -POLICY LIMIT $ $1,600,000 DESCRIPTION OF OPERATIONS I LOCATIONS /VEHICLES (ACORD 101, Additional Remarks Schedule, maybe attached if more space is required) GL Additional Insured applies perform CG20100704 & CG20370704 attached, only if required by written contractlagreement. GL Primary wording applies per AP5031 US (04-10) attached. Re: #314 Grade 5 Repairs Phase 7. . Additional Insured(s): Costa Mesa Sanitary District, its directors, officials, officers, employees, agents, and volunteers. The Certificate of Insurance is subject to policy terms, conditions, limitations and exclusions. CERTIFICATE HOLDER CANCELLATION #314 Grade 5 Repairs Phase 7 Costa Mesa Sanitary District /� 290 Paularino Avenue /J bl l Costa Mesa, CA 92626 _1\//y✓7 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. J AUTHORIZED REPRESENTATIVE Melonie Harbo (1tjK/. Y/—/(jl_/w\••,�• (`(h'+((-�` ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD 34635908 1 ROBOSEW-01 1 16'-17 GL, XS 6 WC, 16-17 AUTO I Bolton Certificate Processing 1 3/13/2017 6:07:49 PM (POT) I Page 1 of 4 POLICY NUMBER: 000506276 COMMERCIAL GENERAL LIABILITY CG 20 10 07 04 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - OWNERS, LESSEES OR CONTRACTORS - SCHEDULED PERSON OR ORGANIZATION This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Name of Additional Insured Person(s) or Organ izations : Locations(s) of Covered Operations Where Required By Written Contract Or Agreement All Projects Of The Named Insured Information required to complete this Schedule, if not shown above, will be shown in the Declarations. A. Section II — Who Is An Insured is amended to include as an additional insured the person(s) or organization(s) shown in the Schedule, but only with respect to liability for "bodily injury", "property damage' or "personal and advertising injury' caused, in whole or in part, by: 1. Your acts or omissions; or 2. The acts or omissions of those acting on your behalf; in the performance of your ongoing operations for the additional insured(s) at the location(s) desig- nated above. CG 20 10 07 04 B. With respect to the insurance afforded to these additional insureds, the following additional exclu- ions apply: This insurance does not apply to "bodily injury" or '.property damage" occurring after: 1. All work, including materials,. pads or equip- ment furnished in connection with such work, on the project (other than service, maintenance or repairs) to be performed by or on behalf of the additional insured(s) at the location of the covered operations has been completed; or 2. That portion of "your work" out of which the injury or damage arises has been put to its in- tended use by any person or organization other than another contractor or subcontractor en- gaged in performing operations for a principal as a part of the same project. © ISO Properties, Inc., 2004 34635908 1 ROBOSEW-01 1 16-17 GL, XS 6 WC, 16-17 AUTO I Bolton Certificate Processing 1 3/13/2017 6:07:49 PM (PDT) I Page 2 of 4 Page 1 of 1 POLICY NUMBER: 000506276 COMMERCIAL GENERAL LIABILITY CG 20 37 07 04 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - OWNERS, LESSEES OR CONTRACTORS - COMPLETED OPERATIONS This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Name of Additional Insured Person(s) or Organization(s): Locations and Description of Covered Operations Where Required By Written Contract Or Agreement All Projects Of The Named Insured Information required to complete this Schedule, if not shown above, will be shown in the Declarations. Section II - Who Is An Insured is amended to include as an additional insured the person(s) or organization(s) shown in the Schedule, but only with respect to liability for "bodily injury" or "property dam- age" caused, in whole or in part, by "your work' at the location designated and described in the sched- ule of this endorsement performed for that additional insured and included in the "products -completed operations hazard." CG 20 37 07 04 © ISO Properties, Inc., 2004 Page 1 of 1 34635900 1 ROBOSEW-ol 116-17 GL, %5 6 WC, 16-17 AUTO I Bolton Certificate Processing 1 3/13/2017 6:07:49 PM (PDT) I Page 3 of 4 000506276 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. PRIMARY AND NON CONTRIBUTORY ENDORSEMENT This endorsement modifies insurance provided under the following: ALL COVERAGE PARTS Name Of Additional Insured Person(s) Or Organization(s): Where Required By Written Contract or Agreement If no entry appears above, this endorsement applies to all Additional Insureds covered under this policy. Any coverage provided to an Additional Insured under this policy shall be excess over any other valid and collectible insurance available to such Additional Insured whether primary, excess, contingent or on any other basis unless a written contract or written agreement specifically requires that this insurance apply on a primary and noncontributory basis. ALL OTHER TERMS AND CONDITIONS OF THE POLICY REMAIN UNCHANGED. AP5031 US 04-10 Page 1 of 1 34635908 1 ROBOSEW-01 116-17 GL, XS s WC, 16-17 AUTO I Bolton Certificate Processing 1 3/13/2010 6:07:49 PM (PBT) I Page 4 of 4