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Insurance - Municipal Maintenance - 2017-12-29Lf DATE A� CERTIFICATE OF LIABILITY INSURANCE 12/ 91201MDDYYYY) 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 CONSTIT&E 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 Palle ies) must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED, to the terms tthhe subject and conditions off policy, certain policies may require an endorsement. A statement on this certificate does not confer nghts to the certificate holder in lieu of such endorsement(s). PRODUCER Bert Lyon CONTACT NAM . Santry Customer Se . PHONE FAX C Ext), 800-447-0633 WC 1,14• 888-533-7827 EMAIL A X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE M OCCUR ADDRESS: businessprolucts ssdodsontrycom INSURER(S) AFFORDING COVERAGE NAIC M 49677]6004 INSURER A: Sentry Select Insurance Company 21180 12/15/2018 INSURED INSURER B: Municipal Maintenance Equipment Inc 4634 Mayhew Rd INSURER C: INSURER D Sacramento, CA 95827-9700 GENERAL AGGREGATE $1,500,000 INSURER E $ INSURER F: COVERAGES CERTIFICATE NUMBER: 938354 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. INSRADDL LTR TYPE OF INSURANCE INSR SUBR WVD POLICYNUMBER POLICY EFF M/DD POLICY EXP M/DD LIMITS A X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE M OCCUR % 47 49677]6004 12/15/2017 12/15/2018 EACH OCCURRENCE $ 500,000 DAMAGE TO RENTED PREMISES aoccunance $100,000 MED EXP (!my one person) $ 5,000 PERSONAL & ADV INJURY $ 500,000 GENT AGGREGATE LIMB APPLIES PER X POLICY J"r 0LOC OTHER: GENERAL AGGREGATE $1,500,000 PRODUCTS - OOMP/OP AGG $1,500,000 $ A AUTOMOBILE LIABILITY X ANY AUTO OWN ONLY AU�TOSULED HIRED NON -OWNED AUTOS ONLY AUTOS ONLY 8967776005 12/15/2017 12/15/2018 COMBINED SINGLE LIMIT $ 500,000 BODILY INJURY (Par Person) $ BODILY INJURY (Per accidar0 $ PROPERTYDAMADE er acf4d $ A X UMBRELLA LIAR X EXCESS LIAR % OCCUR CLAIMS -MADE 4967776006 12/15/2017 12/15/2018 EACH OCCURRENCE $ 3,000,000 AGGREGATE $ 9,000,000 DED RETENTION $ PRODUCTS - COMP/OP AGG $ 9,000,000 WORKERS COMPENSATION ANDEMPLOYERS' LIABILITY Y/N ANY PROPRIETOR/PARTNER/EXECUFIVE❑ OFFICERIMEMBER EXCLUDED? (Mandatory in NH) it yes, describe under DESCRIPTION OF OPERATIONS below N/A PER OTH- STA ER E.L EACH ACCIDENT $ E.L. DISEASE - EA EMPLOYEE $ E.L DISEASE -POLICY LIMIT $ DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached N more space is required) Refer to attached CERTIFICATE HOLDER CANCELLATION Costa Masa Sanitary District SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE 290 Paularino Ave THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Costa Mesa, CA 92626-3314v� `111?sto ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE 47 ACORD 25 (2016/03) 4967776 Sentry Select Insurance Company 1 00001 0000008568 18002 0 N Page 1 of 2 ®1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD 12/29/2017 35087445-3584-4C33-923D-D7911E17570A 0027020044343384667392626331490 BeH Lyon POLICY NUMBER 4967776004 CARRIER Sentry Seled Insurance Company AGENCY CUSTOMER ID: )00O 3697 LOC #: ADDITIONAL REMARKS SCHEDULE Page Y of Y NAMED INSURED Municipal Maintenance EquipmerR Inc NAIC CODE 21160 I EFFECTIVE DATE: 12/15/2017 THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, FORM NUMBER: AGORD 25 FORM TITLE: Certificate of Liability Insurance General Liability COSTA MESA SANITARY DISTRICT, THEIR ELECTED AND APPOINTED OFFICIALS, AGENTS, OFFICERS, VOLUNTEERS, AND EMPLOYEES AS ADDITIONAL INSURED- PERSUANTTO ATTACHED ENDORSEMENT.ANY OTHER INSURANCE MAINTAINED BY THE COSTA MESA SANITARY DISTRICT SHALL BE EXCESS & NON-CONTRIBUTORING WITH THE INSURANCE PROVIDED BY THIS POLICY. UMBRELLA IS EXCESS OVER GENERAL LIABILITY AND AUTO LIABILITY POLICIES. ACORD 101 (2008/01) © 2008 ACORD CORPORATION. All rights reserved. 4967776 The ACORD name and logo are registered marks of ACORD 12/29/2017 Sentry Select Insurance Company POLICY NUMBER: 4967776004 COMMERCIAL GENERAL LIABILITY CG 2010 0413 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 Organization(s) Location(s) Of Covered Operations Costa Mesa Sanitary District All Locations Description: ALL JOBS 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) designated above. However: 1. The insurance afforded to such additional insured only applies to the extent permitted by law; and 2. 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. Change effective 12/28/2017 CG 20 10 0413 4967776 Sentry Select Insurance Company 1 00001 0000008569 18002 0 N B. With respect to the insurance afforded to these additional insureds, the following additional exclusions apply: This insurance does not apply to "bodily injury" or "property damage" occurring after: 1. All work, including materials, parts or equipment 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 intended use by any person or organization other than another contractor or subcontractor engaged in performing operations for a principal as a part of the same project. © Insurance Services Office, Inc., 2012 64A4D3E1-350A-4802-AB2B-5FF7D8AE4873 0027020044343384663992626331490 Page 1 of 2 12/29/2017 C. 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 Page 2 of 2 4967776 Sentry Select Insurance Company 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. Change effective 12/28/2017 © Insurance Services Office, Inc., 2012 CG 20 10 04 13 12/29/2017