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Insurance - Robotic Sewer Solutions, Inc. 2017-11-20A� �® CERTIFICATE OF LIABILITY INSURANCE DATE (MM DDYYYYI 11/20/2017 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). PRODUCERrI Bolton & Company 3475 E. Foothill Blvd., Suite 100 Pasadena, CA 91107 CONTACT NAME: PHONE FAX Ext: 62s 799-7000 AIc No): 626 583-2117 E,nN� ADDRESS: INSURERS AFFORDING COVERAGE NAIC# 11/22/2017 INSURERA: James River Insurance Company ! 12203 www.bollonco com 0008309 INSURED Robotic Sewer Solutions, Inc. 1111 Foothill Boulevard, Suite B La Canada, CA 91011 INSURER B: Stale Compensation Insurance Fund of CA 35076 INSURER C: Capped al $10 000 000 INSURER D: StarStoneSpecialty Insurance Company/ 44776 INSURER E: PRODUCTS - COMP/OP AGG $2,000,000 $ INSURER F: AUTOMOBILE LIABILITY ANY AUTO OWNED SCHEDULED AUTOS ONLY AUTOS HIRED NON -OWNED AUTOS ONLY AUTOS ONLY ✓ CnVFRACtFS CFRTIFICATF NIIMRFR- 2R09SRS9 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. INSR LTR TYPE OF INSURANCE AODL SUe, POLICYNUMBER NIMRIDYEFF MMILDILDV EXP LIMITS COMMERCIAL GENERAL LIABILITY CLAIMS -MADE 1✓ OCCUR Per Project Aggregate �/ 000506277 11/22/2017 11/22/2016 EACH OCCURRENCE $1,000,000 PREMSES EaoNcuE encs $50,000 ./ MED EXP (Anyone person) $ Excluded ✓ GEN'L Capped al $10 000 000 PERSONAL & ADV INJURY $1,000,000 AGGREGATE LIMIT APPLIES PER: POLICY✓Z jE0 LOC OTHER: GENERAL AGGREGATE $2,000,000 PRODUCTS - COMP/OP AGG $2,000,000 $ AUTOMOBILE LIABILITY ANY AUTO OWNED SCHEDULED AUTOS ONLY AUTOS HIRED NON -OWNED AUTOS ONLY AUTOS ONLY ✓ COMBINED SINGLE LIMIT $ Ea accident BODILY I NJURY(Par person) $ BODILY INJURY (Par accident) $ PROPERTY DAMAGE $ Peraccahm D UMBRELLALIAS EXCESS LIAR �/ OCCUR CLAI:MADE 87446H17ALI 11/22/2017 11/22/2018 EACH OCCURRENCE $4000000 AGGREGATE s4,000.000 DED ✓ I RETENTION $0 $ B WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANYPROPRIETORIPARTNEWEXECUTIVE YIN OFFICERIMEMBEREXCLUDED?Fy� (Mandatory In NH) If yes, describe under DESCRIPTION OF OPERATIONS below NIA 198026417 11/22/2017 11/22/2018 ,/ STATUTE ERI E.L. EACH ACCIDENT $$1,000,000 E.L. DISEASE - EA EMPLOYEE $ $1,000,000 E.L. DISEASE -POLICY LIMIT $$1000000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORO 101, Additional Remarks Schedule, maybe attached if more space is required) GL Additional Insured applies per CG20120798 Endorsement to Follow. Auto Additional Insured applies per SS03010111 attached. Additional Insured(s): The Costa Mesa Sanitary District, it's elected and appointed officials, agents, officers, volunteers and employees. The Certificate of Insurance is subject to policy terms, conditions, limitations and exclusions. f COTICIPATC Uni PIFR CANCFI I ATION Costa Mesa Sanitary DIStfICt ry / 290 Paularino Avenue Costa Mesa, CA 92626 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. gUTH00.QEDREPRESENTATNE Jennifer Tucker �`/l�f/r_'r�•L r(`,•a�•' U 1 M88-ZU10 ACUKU CUKI-UKA I RUN. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD 18925652 1 ROBOSEW-01 117-18 GL, XS E WC, 17-18 1 Michael Lawson 1 11/20/2017 4:36:41 PM (PST) I Page 1 of 1 ACCW?a CERTIFICATE OF LIABILITY INSURANCE DATE (MMIDDIYYYY) L. / vz0/zon 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 r1 Bolton & Company 3475 E. Foothill Blvd., Suite 100 Pasadena, CA 91107 CONTACT NAME: PHONE 626 799-7000 ac No: 626 583-2117 tAfC No EM) E-MAIL ADDRESS: INSURERS AFFORDING COVERAGE NAIC# 11/22/2017 INSURERA: James River Insurance Company 12203 www.boltonco.com 0008309 INSURED Robotic Sewer Solutions, Inc. INSURER B: State Compensation Insurance Fund of CA 35076 1111 Foothill Boulevard, Suite B INSURER C: MED EXP (Any one person) $ Excluded INSURER D: StarStoneSpecialty Insurance Company44776 ✓ Per Project Aggregate La Canada, CA 91011 INSURER E: INSURER F: ✓ Capped al $10 000 000 PERSONAL& ADV INJURY $1,000,000 COVERAGES CERTIFICATE NIIMRFR• ga099991 RFVISinm NIIMRFR- 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 LTR TYPE OF INSURANCE ADDLSUBR POLICYNUMBER POLICYEFF (MWDQ= POLICY EXP IMMIDDIff'r(ILIMITS A r/ COMMERCIAL GENERAL LIABILITY ✓ 000506277 11/22/2017 11/22/2016 EACH OCCURRENCE $1000000 CLAIMS -MADE F✓ OCCUR DAMAGE TO PREMISES EaENTED occurrence $50,000 MED EXP (Any one person) $ Excluded ✓ Per Project Aggregate ✓ Capped al $10 000 000 PERSONAL& ADV INJURY $1,000,000 GEHL AGGREGATE LIMIT APPLIES PER: GENERALAGGREGATE $2,000,000 POLICY✓❑JECOT LOC PRODUCTS-COMPIOPAGG $2000000 $ OTHER: AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ Ea accident) 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 87446H17ALI 11/22/2017 11/22/2016 EACH OCCURRENCE $¢000000 EXCESS LIAB CLAIMS -MADE AGGREGATE $¢000000 DED I ✓ I RETENTION$O I I $ B WORKERS COMPENSATION AND EMPLOYERS' LIABILITY YIN ✓ 198026417 11/22/2017 11/22/2016 ✓ PER R STATUTE ETH E.L. EACH ACCIDENT $$1.000,000 O OFFCERIMEMB ERED?ECUTIVE ] NIA E.L. DISEASE -EA EMPLOYE $$I QQO,000 (Mandatory In NH) descnbe under E.L. DISEASE -POLICY LIMIT $$1000000 Ues, SCRIPTIONOFOPERATIONSbalow DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) GL Additional Insured applies per form CG20100704 & CG20370704 attached, only if required by written contract/agreement. 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. Costa Mesa Sanitary District 290 Paularino Avenue Costa Mesa, CA 92626 ACORD 25 (2016/03) 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 III �...� a } �J(V-- Jennifer Tucker rc1196R-20'15 ACORn CnRPORATIr1N All rinM< r...r —r! The ACORD name and logo are registered marks of ACORD 38925653 1 ROBOSEW-01 1 17-18 GL, XS E WC, 17-18 1 Michael Lawson 111/20/2017 4:36:41 PM (PST) I Page 1 of 4 POLICY NUMBER: 000506277 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 38925653 1 ROBOSEW-01 117-1B 6L, XS & WC, 17-18 1 Michael Lawson 1 11/20/2017 4:36:41 PM (PST) J Page 2 of 4 Page 1 of 1 POLICY NUMBER: 000506277 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 38925653 1 ROBOSEW-01 1 17-10 GL, %S & WC, 17-18 Michael Lawson 1 11/20/2017 4:36:41 PM (PST) I Page 3 of 4 000506277 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 Oroanizationfsl: Where Required By Written Contract or Agreement no entry appears above, this endorsement applies to all Additional Insureds covered under 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 38925653 1 dOEOEEW-01 11718 GL, %5 & WC, 17-18 1 V—hael Lawson 111/20/2017 4:36:41 PM (PST) I Page 4 of 4