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Insurance- Manhole Adjusting Inc. 2017-08-31MANHADJ-01 DVANCE ,acoRO' CERTIFICATE OF LIABILITY INSURANCE � 0 7 D813112 Y01 08/31 /27 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 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 License # OK07568 Busby -Stone Risk Management, Acrisure Agency Partner 9201 Camino Media, Suite #250 Bakersfield, CA 93311 NANTACT Dawn R Vance PHONE FAX ac, No, Ext): (661) 665-9150 ac, No :(661) 665-9192 E- AI . dvance@busbystone.com INSURER 5 AFFORDING COVERAGE NAIC K 04/30/2018 INSURER A: Travelers Property Casualty Co of America" 25674 MED EXP (Any oneperson) $ 5'000 INSURED INSURERB:GreatAmerican Insurance CO.,�— 16691 INSURER C : PRODUCTS -COMPIOPAGG 2'000,000 Manhole Adjusting Inc. INSURER D: AUTOMOBILE X 9500 Beverly Road Pico Rivera, CA 90660-2135 INSURER E INSURER I: 04/30/2017 04/30/2018 COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: 1 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 TYPE OF INSURANCE ADDL INSD SUBR MD POLICY NUMBER POLICY EFF POLICY EXP LIMITS A X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE X OCCUR X AUTHORIZED REPRESENTATIVE C04E966229-TCT-17 04/30/2017 04/30/2018 EACH OCCURRENCE $ 1'000'000 DAMAGE TO RENTED 300,000 a occurrence $ MED EXP (Any oneperson) $ 5'000 PERSONAL B ADV INJURY 1 11000'000 GEN'L AGGREGATE LIMIT APPLIES PER: I POLICY JE`R ❑X LOC X OTHER: GENERAL AGGREGATE $ 2'000'000 PRODUCTS -COMPIOPAGG 2'000,000 POLLUTION $ 1,000,000 A AUTOMOBILE X LIABILITY ANY AUTO OWNED SCHEDULED AUTOS ONLY AUTOS SSW AUTOS ONLY AUUTNOS ONLDV X 8104E97743A-TCT-17 04/30/2017 04/30/2018 COMBINED SINGLE LIMIT 1,000,000 Ea accident $ BODILY INJURY Per emen $ BODILY INJURY Per accident $ Perry cidenDAMAGE $ B X UMBRELLA LIAR EXCESS LIAR X OCCUR CLAIMS -MADE T000736636.03 04/30/2017 04/30/2018 EACH OCCURRENCE $ 5,000,000 AGGREGATE $ DED I X RETENTION$ 10,000 Aggregate 51000,000 A WORKERS COMPENSATION AND EMPLOYERS LIABILITY OFFICERIMEMBEER EXCLUDED XECUTIVE YIN (Mandatory in Nll) If yes, descnbe under DESCRIPTION OF OPERATIONS below NIA X DTJUB4E86081-6.17 04/30/2017 04/30/2018 X SEATUTE 0ER E.L. EACH ACCIDENT $ 1,000,000 E. L. DISEASEEA EMPLOYEE $ 1'000'000 E.L. DISEASE -POLICY LIMIT 1,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES ACORD 101, Additional Remarks Schedule. may be attached If more space Is required) Adjust and Surface Repair eighteen (18) Sewer anholes, Project No. 311, Phase 5, MAI's Job No. MP17-14051 The Costa Mesa Sanitary District, its elected and appointed officials, agents, officers, volunteers and employees are additional insureds for each of the above policies (except Work Comp) as required per signed written contract, subject to policy terms and conditions. Waiver of subrogation applies as required per written contract. Coverage is primary and non-contributory CERTIFICATE HOLDER CANCELLATION ACORD 25 (2016/03) ©1988-2015 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. �I AUTHORIZED REPRESENTATIVE Costa Mesa Sanitary District 290 Paularino AvenueCosta Mesa CA 92626 ACORD 25 (2016/03) ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD TRAVELERS/�, WORKERS COMPENSATION AND ONE TOWER SQUARE EMPLOYERS LIABILITY POLICY HARTFORD, CT 06183 ENDORSEMENT WC 99 03 76 ( A) — 001 POLICY NUMBER: DTJUB-4E86081-6-17 WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT - CALIFORNIF (BLANKET WAIVER) 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. The additional premium for this endorsement shall be 03.000 % of the California workers' compensation pre- mium. Schedule Person or Organization Job Description ANY PERSON OR ORGANIZATION FOR WHICH THE INSURED HAS AGREED BY WRITTEN CONTRACT EXECUTED PRIOR TO LOSS TO FURNISH THIS WAIVER. 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 04/30/2017 Policy No. DTJUB-4E86081-6-17 Endorsement No. Insured Manhole Adjusting, Inc. Premium Insurance Company Travelers Property Casualty Company of America Countersigned by DATE OF ISSUE: 04/30/17 ST ASSIGN: Page 1 of 1 POLICY NUMBER C04E966229-TCT-17 COMMERCIAL GENERAL LIABILITY ISSUE DATE: 04/30/2017 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 Names of Additional Insured Person(s) or Organization(s): The Costa Mesa Sanitary District, its elected and appointed officials, agents, officers, volunteers and employees Location of Covered Operations: Project No. 311, Phase 5 (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 in- clude 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", "personal injury" or "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. B. With respect to the insurance afforded to these additional insureds, the following additional exclu- sions apply: This insurance does not apply to 'bodily injury' or "property damage" occurring, or "personal injury" or "advertising injury" arising out of an offense committed, after: 1. All work, including materials, parts or equip- ment furnished in connection with such work, on the project (other than service, mainte- nance or repairs) to be performed by or on behalf of the additional insured(s) at the loca- tion of the covered operations has been com- pleted; 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 subcontrac- tor engaged in performing operations for a principal as a part of the same project. CG D3 6103 05 Copyright 2005 The St. Paul Travelers Companies, Inc. All rights reserved. Page 1 of 1 Includes copyrighted material of Insurance Services Office, Inc. with its permission. POLICY NUMBER: C04E966229-TCT-17 COMMERCIAL GENERAL LIABILITY CG 20120798 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED STATE OR POLITICAL SUBDIVISIONS - PERMITS This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE State or Political Subdivision: The Costa Mesa Sanitary District, its elected and appointed officials, agents, officers, volunteers and employees 290 Paularino Avenue Costa Mesa, CA 92626 (If no entry appears above, information required to complete this endorsement will be shown in the Declarations as applicable to this endorsement.) Section II — Who Is An Insured is amended to include as an insured any state 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 political subdivision has issued a permit. 2. This insurance does not apply to: a. "Bodily injury," "property damage" or "personal and advertising injury" arising out of operations performed for the state or municipality; or b. "Bodily injury" or "property damage" included within the "products -completed operations hazard". CG 20120798 Copyright, Insurance Services Office, Inc'1997 Company Profile Company Profile Company Search Company Search Results Company Information Old Company Names Agent for Service Reference Information NAIC Group List Lines of Business Workers' Compensation Complaint and Request for Action/Appeals Contact Information Financial Statements PDF's Annual Statements Quarterly Statements Company Complaint Company Performance & Comparison Data Company Enforcement Action Composite Complaints Studies Additional Info Find A Company Representative In Your Area View Financial Disclaimer COMPANY PROFILE Company Information Old Company Names GREAT AMERICAN INSURANCE COMPANY 301 E. FOURTH STREET CINCINNATI, OH 45202-4201 800-545-4269 Effective Date AMERICAN CONTINENTAL INSURANCE COMPANY 12/06/1976 MANUFACTURERS & MERCHANTS INDEMNITY CO. 09/05/1956 SELECTIVE INSURANCE COMPANY 06/15/1972 Agent For Service Vivian Imperial 818 WEST SEVENTH STREET SUITE 930 LOS ANGELES CA 90017 Reference Information NAIC #: 16691 California Company ID #: 1301-1 Date Authorized in California: 10/17/1945 License Status: UNLIMITED -NORMAL Company Type: Property & Casualty State of Domicile: OHIO back to top NAIC Group List NAIC Group #: 0084 American Financial Grp Lines Of Business The company is authorized to transact business within these lines of insurance. For an explanation of any of these terms, please refer to the glossary. AIRCRAFT AUTOMOBILE BOILER AND MACHINERY BURGLARY COMMON CARRIER LIABILITY CREDIT DISABILITY FIRE LIABILITY MARINE Page 1 of 2 https://interactive.web.insurance.ca.gov/companyprofile/companyprofile?event=companyP... 8/30/2017 Company Profile Company Profile Company Search Company Search Results Company Information Old Company Names Agent for Service Reference Information NAIC Group List Lines of Business Workers' Compensation Complaint and Request for Action/Appeals Contact Information Financial Statements PDF's Annual Statements Quarterly Statements Company Complaint Company Performance & Comparison Data Company Enforcement Action Composite Complaints Studies Additional Info Find A Company Representative In Your Area View Financial Disclaimer COMPANY PROFILE Company Information TRAVELERS PROPERTY CASUALTY COMPANY OF AMERICA ONE TOWER SQUARE HARTFORD, CT 06183 866-336-2077 Old Company Names Effective Date TRAVELERS INDEMNITY COMPANY OF ILLINOIS (THE) 01/12/2005 Agent For Service KARISSA LOWRY 2710 GATEWAY OAKS DRIVE SUITE 15ON SACRAMENTO CA 95833 Reference Information NAIC #: 25674 California Company ID #: 2495-0 Date Authorized in California: 04/16/1982 License Status: UNLIMITED -NORMAL Company Type: Property & Casualty State of Domicile: CONNECTICUT back to top NAIC Group List NAIC Group =. 3548 Travelers Grp Lines Of Business The company is authorized to transact business within these lines of insurance. For an explanation of any of these terms, please refer to the glossary. AIRCRAFT AUTOMOBILE BOILER AND MACHINERY BURGLARY COMMON CARRIER LIABILITY FIRE LIABILITY MARINE MISCELLANEOUS PLATE GLASS SPRINKLER SURETY Page 1 of 2 https://interactive.web.insurance.ca.gov/companyprofile/companyprofile?event=companyP... 8/30/2017 Great American Insurance Company - Company Profile - Best's Credit Rating Center A.M. Best Rating Services Great American Insurance Company (, A.M. Best #: 002213 NAIC #: 16691 FEIN #: 310501234 Domiciliary Address 301 E. Fourth Street Cincinnati, OH 45202 United States Web: www.greatamericaninsurancegroup.com Phone: 513-369-5000 Fax: 513-369-3600 Rrrerrchl .. 4 BEST A+,, or Assigned to insurance companies that have, in our opinion, a superior ability to meet their ongoing insurance obligations. Page 1 of 3 View additional news, reports and products for this company. Based on A.M. Best's analysis, 058317 - American Financial Group, Inc is the AMB Ultimate Parent and identifies the topmost entity of the corporate structure. View a list of operating entities entities in this structure. Best's Credit Ratings Financial Strength Rating View Definition Rating: Financial Size Category: Outlook: Action: Effective Date: Initial Rating Date: Long -Term Issuer Credit Rating View Definition Long -Term: Outlook: Action: Effective Date: Initial Rating Date: u Denotes Under Review Best's Rating Best's Credit Rating Analyst Rating Issued by: A.M. Best Rating Services, Inc. Senior Financial Analyst: Gregory Dickerson Director: Jennifer Marshall, CPCU, ARM Disclosure Information View A.M. Best's Rating Disclosure Form A+ (Superior) XIV ($1.5 Billion to $2 Billion) Stable Affirmed August 11, 2017 September 30, 1908 as - Stable Affirmed August 11, 2017 June 17, 2005 A.M. Best Affirms Credit Ratings of American Financial Group. Inc. and Most of Its Insurance Subsidiaries TV August 11, 2017 Rating History A.M. Best has provided ratings & analysis on this company since 1908. Financial Strength Rating http://www3.ambest.comlratings/entitiesICompanyProfile.aspx?ambnum--2213 &URatingl... 8/30/2017 Travelers Property Casualty Company of America - Company Profile - Best's Credit Rati... Page 1 of 3 A.M. Best Rating Services Travelers Property Casualty Company of America (z) A.M. Best #: 004461 NAIC #: 25674 FEIN #: 362719165 as+ Domiciliary Address Financial strength Rating One Tower Square ses7 Do Hartford, CT 06183 A++ superior United States Assigned to insurance companies that Outlook: have, in our opinion, a superior ability to Web: www.travelers.com meet their ongoing insurance obligations. Phone: 860-277-0111 July 22, 2016 Fax: 860-277-7002 View additional news, reports and products for this company. Based on A.M. Best's analysis, 058470 - The Travelers Companies, Inc. is the AMB Ultimate Parent and identifies the topmost entity of the corporate structure. View a list of operating insurance entities in this structure. Best's Credit Ratings as+ Financial Strength Rating View Definition i Rating: A++ (Superior) Affiliation Code: g (Group) Financial Size Category: XV ($2 Billion or greater) Outlook: Stable Action: Affirmed i j Effective Date: July 22, 2016 Initial Rating Date: June 30, 1972 Long -Term Issuer Credit Rating View Definition Long -Tenn: as+ Outlook: Stable Action: Affirmed Effective Date: July 22, 2016 Initial Rating Date: April 18, 2005 u Denotes Under Review Best's Rating Best's Credit Rating Analyst Rating Issued by: A.M. Best Rating Services, Inc. Senior Financial Analyst: Gregory Dickerson Director: Jennifer Marshall, CPCU, ARM Disclosure Information View A.M. Best's Rating Disclosure Form —; A.M. Best Affirms Ratings of The Travelers Companies, Inc. and Its Subsidiaries July 22, 2016 Rating History A.M. Best has provided ratings R analysis on this company since 1972. http://www3.ambest.com/ratings/entities/CompanyProfile.aspx?ambnum=4461 &URatingI... 8/30/2017