Insurance - C & R Drains -2017-09-21ACC>Rb® CERTIFICATE OF LIABILITY INSURANCE
MM00/
07/d120177
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 terns 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 endorsements .
PRODUCER
FEDERATED MUTUAL INSURANCE COMPANY
HOME OFFICE: P.O. BOX 328
CONTACTNAME: CLIENT CONTACT CENTER
n/cNNo Est): 888-333-4949 A/G Rol: 507-446-4664
ADDRESS: CLIENTCONTACTCENTER FEDINS.COMOWATONNA, MN 55060
INSURER(S) AFFORDING COVERAGE NAIC #
09/10/2017
INSURER A: FEDERATED MUTUAL INSURANCE COMPANY/ 13935
EACH OCCURRENCE $1,0D0,000
INSURED 310410-6 INSURER B:
C & R DRAINS INC
1525 MACARTHUR BLVD STE 11
INSURER C:
INSURER D: COSTA MESA, CA 92626-1413
INSURER E:
INSURER F:
AUTOMOBILE
X
COVERAGES CERTIFICATE NUMBER: 78 REVISION NUMBER: 0
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.
INSRTR TYPE OF INSURANCE DLINSR SUERWVD POLICY NUMBER POLICY EFF
MMIDDIYYVV
POLICY EXP
MMIDDI YYV LIMITS
A
COMMERCIAL GENERAL LIABILITY
CLAIMS -MADE X OCCUR
BUSINESS OWNER'S LIABILITY
Y Y 0696048 09/10/2017 09/10/2018
EACH OCCURRENCE $1,0D0,000
DAMAGE ( Ea
oRENTED $
100,000Sccurrence
X
GEN'L
X
MED EXP (My one person)
PERSONAL& ADV INJURY $1,000,000
AGGREGATE LIMIT APPLIES PER:
POLICY JECT LOCPRO-
OTHER:
GENERAL AGGREGATE $2,000,000
PRODUCTS- COMPIOP AGO $2,000,000
A
AUTOMOBILE
X
LIABILITY
ANY AUTO
SCHEDULEDOWNEDAUTOSONLYAUTOS
HIRED AUTOS ONLY NON -OWNED
AUTOS ONLY
N N 0696049 09/10/2017 09/10/2018
COMBINED SINGLE LIMIT $1,000,000
Ea accidentBODILYINJURY (Per person)
BODILY INJURY (Per accident)
PROPERTY DAMAGE
Per accitlen
A
X UMBRELLA LIAB
EXCESS LIAB
X OCCUR
CLAIMS -MADE N N 0696050 09/10/2017 09/10/2018
EACH OCCURRENCE $1,000,000
AGGREGATE $1,000,000
DED RETENTION
WORKERS COMPENSATION
AND EMPLOYERS' LIABILITY YIN
ANV PROPRIETOR/RIEXECUTIVE "
NIAEXCLUDED? OFFICERIMEMBER EXCLUDED?
Mandatory in NH)
11 yes, describe under
DESCRIPTION OF OPERATIONS below
N / A
OTH- PER STATUTE ER
E.L. EACH ACCIDENT
E.L. DISEASE - EA EMPLOYEE
E.L. DISEASE - POLICY LIMIT
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be aaatlied it more space is required)
SEE ATTACHED PAGE
780
COSTA MESA SANITARY DISTRICT
628 W 19TH ST ,
y COSTA MESA, CA 92627-2716 1 y-T I, iB //I
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
AUTHORIZED REPRESENTATIVE
ACORD CORPORATION All rinhfo rncnrvrrd
ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD
ACOR"
L
AGENCY CUSTOMER ID: 310-410-6
LOC #:
ADDITIONAL REMARKS SCHEDULE Page 1 of 1
AGENCY NAMED INSURED
FEDERATED MUTUAL INSURANCE COMPANY C & R DRAINS INC
1525 MACARTHUR BLVD STE 11
COSTA MESA, CA 92626-1413POLICYNUMBER
SEE CERTIFICATE # 78.0
CARRIER NAIC CODE
SEE CERTIFICATE # 78.0 EFFECTIVE DATE: SEE CERTIFICATE # 78.0
THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM,
FORM NUMBER: 25 FORM TITLE: CERTIFICATE OF LIABILITY INSURANCE
COSTA MESA SANITARY DISTRICT, THEIR ELECTED AND APPOINTED OFFICIALS, AGENTS, OFFICERS, VOLUNTEERS, AND EMPLOYEES
LISTED AS ADDITIONAL INSURED
INSURANCE PROVIDED BY THE BUSINESSOWNERS LIABILITY IS PRIMARY AND NONCONTRIBUTORY OVER OTHER INSURANCE.
BUSINESSOWNERS LIABILITY CONTAINS A WAIVER OF SUBROGATION IN FAVOR OF THE CERTIFICATE HOLDER SUBJECT TO THE
CONDITIONS OF THE BLANKET WAIVER OF TRANSFER OF RIGHTS OF RECOVERY ENDORSEMENT.
FOR REASONS OTHER THAN NON-PAYMENT OF PREMIUM, 30 DAYS NOTICE WILL BE PROVIDED TO THE CERTIFICATE -HOLDER IN THE
EVENT THAT THE ISSUING COMPANY CANCELS THE POLICY BEFORE THE EXPIRATION DATE OF THE POLICY.
COMMERCIAL UMBRELLA FOLLOWS FORM ACCORDING TO THE TERMS, CONDITIONS, AND ENDORSEMENTS FOUND IN THE COMMERCIAL
UMBRELLA POLICY.
ACORD 101 (2008/01) O 2008 ACORD CORPORATION. All rights reserved.
The ACORD name and logo are registered marks of ACORD
Additional Insured Copy
FEDERATED INSURANCE COMPANIES
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:
BUSINESSOWNERS LIABILITY COVERAGE FORM
SCHEDULE
State Or Governmental Agency or Subdivision or Political Subdivision:
COSTA MESA SANITARY DISTRICT
628 W 19TH ST
COSTA MESA CA 92627
The following is added to Paragraph C. Who Is An
Insured:
4. Any state or governmental agency or subdivision
or political subdivision shown in the Schedule is
also an insured, subject to the following
provisions:
a. 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.
Insured:
C & R DRAINS INC
1525 MACARTHUR BLVD STE 11
COSTA MESA CA 92626
b. This insurance does not apply to:
1) "Bodily injury", "property damage", or
personal and advertising injury" arising
out of operations performed for the state
or municipality; or
2) "Bodily injury" or "property damage"
included within the "products -completed
operations hazard".
Place of Issue:
FEDERATED MUTUAL INSURANCE COMPANY
Home Office
121 East Park Square
Owatonna, MN 55060
507) 455-5200
Includes copyrighted material of Insurance Services Office, Inc., with its permission.
BP -F-254 (08-11) Policy Number: 0696048 Transaction Effective Date: 09-10-2017