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Insurance - GCI Construction, Inc. - Workers' Comp- Pollution 2018-03-01AC R ® CERTIFICATE OF LIABILITY INSURANCE �i DATE (MMIOD rYYY) 3/1 /2018 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 Compass Direct Insurance Services, Inc. 13681 Newport Ave., Ste 8 #622 Tustin, CA 92780 NAME: C Jeremy Seltzer PHONE 714-665-9800 ac No : 714-665-9801 INC No. Emil EWAIL ADDRESS: jeremyc5cdisi.com INSURER(S) AFFORDING COVERAGE NAICN �/ INSURER A: Great American Assurance Company 26344 www.cdisi.com License #OH16100 INSURED GCI Construction, Inc. 1031 Calle Recodo, Ste. D San Clemente CA 92673 INSURER B: Wesco Insurance Company 25011 INSURER C: Insurance Company of the West 27847 INSURER D: RSUI Indemnity Company 22314 INSURER E: AGCS Marine Insurance Company 22837 INSURER F: Westchester Surplus Lines Insurance Co 10172 COVERAGES CERTIFICATE NUMBER: 40638159 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. ILT. TYPE OF INSURANCE INsD SUBR POLICYNUMBER POLICY DDVIYYYY EFF MMIDD EXP LIMITS AI/ COMMERCIAL GENERAL LIABILITY —DAMAGE CLAIMS -MADE F/I OCCUR �/ �/ GLP 1552541 4/1/2017 4/1/2018 EACH OCCURRENCE $1000000 TUR PREMISES E.Eoccuneace $50000 MED EXP (My one person) $Excluded ✓ Owner's/Cont. Pro ✓ XCU/Deductible $5,000 PERSONAL &ADV INJURY $1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERALAGGREGATE $2,000,000 PRODUCTS-COMPIOPAGG $2,000000 POLICY✓❑JEa LOC Errto ee Benifts $1.000,000 OTHER: B AUTOMOBILE LIABILITY ✓ ✓ WPP151620100 4/1/2017 4/1/2018 COMBINED SINGLE LIMIT Ea BIKED $ 1,000000 BODILY INJURY (Per Person) $ ✓ ANY AUTO BODILY INJURY (Per accident) $ OWNED SCHEDULED AUTOS ONLY AUTOS ✓ NE AUTOS ONLY ✓ AUHIREDUTOS ONLDV Comp/Coll Ded$1.000 (Pers TYOAMAGE $ Per Marc)cc $ No Liability Deductible D ✓ UMBRELLA LIAR,/ OCCUR ✓ ✓ NHA242287 4/1/2017 4/1/2016 EACH OCCURRENCE $4000000 AGGREGATE $4,000,000 EXCESS LIAB CLAIMS -MADE $0 Deductible OEDI RETENTIONS $ C WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANYPROPRIETORIPARTNEWEXECUTIVE Y- ✓ WSA5040042 3/17/2018 3/17/2019 �/ STATUTE ERS E. L. EACH ACCIDENT $1,000,000 E.L. DISEASE -EA EMPLOYEE $ OFFICERWEMBEREXCLUDED? (Mandate, in NH) If yes, de scribe under DESCRIPTION OF OPERATIONS below NIA $O Deductible E.L. DISEASE - POLICY LIMIT $1000000 E IM-Eqp./Lesd-Hrd-R MXI 93 076 269 4/1/2017 4/1/2018 Sch/Per:481K/10OK Deductible $1,000 F Pollution G46866435001 2/2/2018 2/2/2019 $2,000,000/$2,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) The Costa Mesa Sanitary District, it's elected and appointed officials, agents, officers, volunteers and employees are additional insureds as per attached endorsements with respects to the operations of the named insured as per contract. RECEIVED CERTIFICATE HOLDER CANCELLATION © 1988-2015 ACORD CORPORA I IIJN. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD 40638159 1 17/10 GL AU man WC IM£/LHR I Nina Lautenschlagex 13/1/2018 12:49:36 PM (PST) I Page 1 of 11 MAR 12 Z013 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Costa Mesa Sanitary District 290 Paularino Avenue Costa Mesa CA 92626 Costs Mesa Sanitary District THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZEDREPRESENTATIVE Jeremy Seltzer © 1988-2015 ACORD CORPORA I IIJN. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD 40638159 1 17/10 GL AU man WC IM£/LHR I Nina Lautenschlagex 13/1/2018 12:49:36 PM (PST) I Page 1 of 11 Great American Assurance Company CG 20 33 GLP 1552541 (Ed 07 04) GCI Construction, Inc. THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - OWNERS, LESSEES OR CONTRACTORS - AUTOMATIC STATUS WHEN REQUIRED IN CONSTRUCTION AGREEMENT WITH YOU This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART A. SECTION II - WHO IS AN INSURED is amended to include as an Additional Insured any person or organization for whom you are performing operations when you and such person or organization have agreed in writing in a contract or agreement that such person or organization be added as an Additional In- sured on your policy. Such person or or- ganization is an Additional Insured only with respect to liability for "bodily injury;' "prop- erty damage" or "personal and advertising in- jury" 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 oper- ations for the Additional Insured. A person's or organization's status as an Ad- ditional Insured under this endorsement ends when your operations for that Additional In- sured are completed. B. With respect to the insurance afforded to these Additional Insureds, the following addi- tional exclusions apply: CG 20 33 (Ed. 07/04) XS This insurance does not apply to: 1. "Bodily injury," "property damage" or "per- sonal and advertising injury" arising out of the rendering of, or the failure to render, any professional architectural, engineering or surveying services, including: a. the preparing, approving, or failing to prepare or approve, maps, shop drawings, opinions, reports, surveys, field orders, change orders or draw- ings and specifications; or b, supervisory, inspection, architectural or engineering activities. 2. "Bodily injury;' or "property damage" oc- curring after: a. 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 b. 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 an- other contractor or subcontractor en- gaged in performing operations for a principal as a part of the same project Copyright, ISO Properties, Inc., 2004 40638159 1 19/18 GL AU LM9 WC IME/LHR I Nina Lautenechlagei 13/1/2018 12:49:36 PM (PST) I Paget of 11 CG 20 12 (Ed. 05 09) 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: COMMERCIAL GENERAL LIABILITY COVERAGE PART Schedule State or Governmental Agency or Subdivision ov Political Subdivision_ Costa Mesa Sanitary District 290 Paularino Avenue Costa Mesa CA 92626 Information required to complete this Schedule, if not shown above, will be shown in the Declarations. SECTION 11 - WHO IS AN INSURED is amended to include as an insured any state or governmental agency or subdivision 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 governmental agency or subdivision or political subdivision has issued a permit or authorization. 2. This insurance does not apply to. a. "bodily injury," "property damage" or "personal and advertising injury" arising out of operations performed for the federal government, state or municipality; or b. "bodily injury" or "property damage' included within the "products -completed operations hazard." [[��(. J/��(� .L�/p�,,[p,� G�/(�(]l [�� Copyright, ISO Properties, Inc., 2008 4XG,91114 L c+Ed. u®5'40%,RRRa-� 1a tene hlagem 1 3/1/2019 Jpaga 4, Off) 11) Page 3 of 11 Great American Assurance Company GLP 1552541 GCI Construction, Inc. CG 20 37 (Ed. 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 Name Of Additional Insured Person(s) or Organ! zation(s): Any person or organization that "you" and such person or organiza- tion have agreed in writing in a contract or agreement that such person or organization be added as an additional insured on "your" policy, but only for "your work" performed during this policy period. Schedule Location and Description of Completed Operations: Per Certificate(s) of Insurance "Your work" performed during this policy period. Additional Premium: Included 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 damage" caused, in whole or in part, by "your work" at the location designated and described in the schedule of this endorsement performed for that Additional Insured and included in the "products -completed operations hazard." Copyright, ISO Properties, Inc., 2004 CG 20 37 (Ed. 07/04) PRO (Page 1 of 1) 40638159 1 17/18 GL AU MR WC IME/LHR I Nina Lautenschlager 1 3/1/2018 12:49:36 PM (PST) I Page 4 of 11 Great American Assurance Company CG 24 04 GLP 1552541 (Ed. 05 09) GCI Construction, Inc. THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. WAIVER OF TRANSFER OF RIGHTS OF RECOVERY AGAINST OTHERS TO US This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE PART Schedule Name of Person or Organization: Any person or organization for whom or on whose behalf 'you" are performing operations when "you" and such person or organization have agreed in writing in a contract or agreement to waive any right of recovery "we" may have against such person or organization. Information required to complete this Schedule, if not shown above, will be shown in the Declarations. The following is added to paragraph 8. Transfer of Rights of Recovery Against Others to Us of SECTION IV - CONDITIONS: We waive any right of recovery we may have against the person or organization shown in the Schedule above because of payments we make for injury or damage arising out of your ongoing operations or "your work" done under a contract with that person or organization and included in the "products—completed operations hazard." This waiver applies only to the person or organization shown in the Schedule above. Copyright, ISO Properties, Inc., 2008 CG 24 04 (Ed. 05/09) PRO (Page 1 of 1) 40638159 1 17/18 GL AU OMB WC IME/LHR I Nina Lautenschlagex 1 3/1/2018 12:49:36 PM (PST) I Page 5 Of 11 Great American Assurance Company GLP 1552541 GCI Construction, Inc. THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. PRIMARY NON-CONTRIBUTORY INSURANCE ENDORSEMENT This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE FORM OWNERS AND CONTRACTORS PROTECTIVE LIABILITY COVERAGE FORM GAC 3649CG (Ed. 11 06) This insurance is primary to any other insurance held by third parties with respect to work performed by you under written contractual agreements with such third parties and any other insurance which may be available to such third parties shall be non—contributory. GAC 3649CG (Ed. 11/06) XS 4063B159 1 17/18 GL A UM WC TME/LR I Nina Lau[ens[hlager 1 3/1/2018 12:49:36 PM (PST) I Page 6 of 11 Great 1Americ n Assurance Company 552541 GCI Construction, Inc. THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. DESIGNATED CONSTRUCTION PROJECTS) GENERAL AGGREGATE LIMIT This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Designated Construction Projects: CG 25 03 (Ed 03 97) Any construction project where "you" are performing operations when 'you" have agreed in writing in a contract or agreement that a separate General Aggregate Limit shall apply to such construction project, but only if "your work" on or at the construction project is performed during the period of this policy. (If no entry appears above, information required to complete this endorsement will be shown in the Declarations as applicable to this endorsement.) A. For all sums which the Insured becomes legally obligated to pay as damages caused by "occurrences' under COVERAGE A. (SECTION 1), and for all medical expenses caused by accidents under COVERAGE C. (SECTION 1), which can be attributed only to ongoing operations at a single designated construction project shown in the Schedule above: 1. A separate Designated Construction Project General Aggregate Limit applies to each designated construction project, and that limit is equal to the amount of the General Aggregate Limit shown in the Declarations. 2. The Designated Construction Project General Aggregate Limit is the most we will pay for the sum of all damages under Coverage A. except damages because of "bodily injury" or "property damage" included in the "products—completed operations hazard," and for medical expenses under Coverage C. regardless of the number of: a. Insureds; b. claims made or "suits" brought; or c. persons or organizations making claims or bringing "suits." Copyright, Insurance Services Office, Inc., 1996 CG 25 03 (Ed. 03/97) PRO (Page 1 of 2) 90638159 1 17/18 GL AN NMS WC IME/LHR I Nina Lautenschlagez 1 3/1/2918 12:99:36 PM (PST) I Page 7 of 11 3. Any payments made under Coverage A. for damages or under Coverage C. for medical expenses shall reduce the Designated Construction Project General Aggregate Limit for that designated construction project. Such payments shall not reduce the General Aggregate Limit shown in the Declarations nor shall they reduce any other Designated Construction Project General Aggregate Limit for any other designated construction project shown in the Schedule above. 4. The limits shown in the Declarations for Each Occurrence, Fire Damage and Medical Expense continue to apply. However, instead of being subject to the General Aggregate Limit shown in the Declarations, such limits will be subject to the applicable Designated Construction Project General Aggregate Limit. B. For all sums which the Insured becomes legally obligated to pay as damages caused by "occurrences" under COVERAGE A. (SECTION 1), and for all medical expenses caused by accidents under COVERAGE C. (SECTION 1), which cannot be attributed only to ongoing operations at a single designated construction project shown in the Schedule above: 1. any payments made under Coverage A. for damages or under Coverage C. for medical expenses shall reduce the amount available under the General Aggregate Limit or the Products -Completed Operations Aggregate Limit, whichever is applicable; and 2. such payments shall not reduce any Designated Construction Project General Aggregate Limit. C. When coverage for liability arising out of the "products -completed operations hazard" is provided, any payments for damages because of "bodily injury' or "property damage" included in the "products -completed operations hazard" will reduce the Products -Completed Operations Aggregate Limit, and not reduce the General Aggregate Limit nor the Designated Construction Project General Aggregate Limit. D. If the applicable designated construction project has been abandoned, delayed, or abandoned and then restarted, or if the authorized contracting parties deviate from plans, blueprints, designs, specifications or timetables, the project will still be deemed to be the same construction project. E. The provisions of LIMITS OF INSURANCE (SECTION III) not otherwise modified by this endorsement shall continue to apply as stipulated. Copyright. Insurance Services Office, Inc.. 1996 CG 25 03 (Ed. 03/97) PRO (Page 2 of 2) 40630159 1 17/18 GL AU OMB WC IME/LHR I Nina Lautenechlagez 1 3/1/3010 12:49:36 PM (PST) I Page 8 of 11 WPP1516201 00 COMMERCIAL AUTO CA 20 48 02 99 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. DESIGNATED INSURED This endorsement modifies insurance provided under the following: BUSINESS AUTO COVERAGE FORM GARAGE COVERAGE FORM MOTOR CARRIER COVERAGE FORM TRUCKERS COVERAGE FORM With respect to coverage provided by this endorsement, the provisions of the Coverage Form apply unless modi- fied by this endorsement. This endorsement identifies person(s) or organization(s) who are "insureds" under the Who Is An Insured Provi- sion of the Coverage Form. This endorsement does not alter coverage provided in the Coverage Form. This endorsement changes the policy effective on the inception date of the policy unless another date is indicated below. Endorsement Effective: 4/1/2017 Countersigned By: �7 w Authorized Representative) Named Insured: GCI Construction, Inc. SCHEDULE Name of Person(s) or Organization(s): Blanket as required by written contract. (If no entry appears above, information required to complete this endorsement will be shown in the Declarations as applicable to the endorsement.) Each person or organization shown in the Schedule is an "insured" for Liability Coverage, but only to the extent that person or organization qualifies as an "insured" under the Who Is An Insured Provision contained in Section II of the Coverage Form. CA 20 48 02 99 Copyright, Insurance Services Office, Inc., 1998 Page 1 of 1 ❑ 40638159 1 17/18 GL AU UMB WC IME/LHR I Nina Lau[enachlager 1 3/1/2018 12:49:36 PM (PST) I Page 9 of 11 W PP1516201 00 COMMERCIAL AUTO CA 04 44 03 10 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. WAIVER OF TRANSFER OF RIGHTS OF RECOVERY AGAINST OTHERS TO US (WAIVER OF SUBROGATION) This endorsement modifies insurance provided under the following: BUSINESS AUTO COVERAGE FORM BUSINESS AUTO PHYSICAL DAMAGE COVERAGE FORM GARAGE COVERAGE FORM MOTOR CARRIER COVERAGE FORM TRUCKERS COVERAGE FORM With respect to coverage provided by this endorsement, the provisions of the Coverage Form apply unless modi- fied by the endorsement. This endorsement changes the policy effective on the inception date of the policy unless another date is indicated below. Named insured: GCI Construction, Inc. Endorsement Effective Date: 4/1/2017 SCHEDULE Name(s) Of Person(s) Or Organization(s): Blanket as required by written contract Information required to complete this Schedule, if not shown above, will be shown in the Declarations. The Transfer Of Rights Of Recovery Against Oth- ers To Us Condition does not apply to the person(s) or organization(s) shown in the Schedule, but only to the extent that subrogation is waived prior to the "ac- cident' or the 'loss" under a contract with that person or organization. CA 04 44 03 10 © Insurance Services Office, Inc., 2009 Page 1 of 1 ❑ 40630159 1 17/18 GL AU OMB WC IME/LHR I Nina Lautenschlager 1 3/1/2018 12:49:36 PM (PST) I Page 10 of 11 COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 04 03 (Ed. 4-84) WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT -CALIFORNIA 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. (This agreement applies only to the extent that you perform work under a written contract that requires you to obtain this agreement from us.) You must maintain payroll records accurately segregating the remuneration of your employees while engaged in the work described in the Schedule. The additional premium for this endorsement shall be 2.00% of the California workers' compensation premium otherwise due on such remuneration. Schedule Person or Organization Job Description Any person or organization as required by written contract This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated. Endorsement Effective 3/17/2018 Policy No. WSA5040042 Endorsement No. WC 04 03 06 Insured GCI Construction, Inc. Premium $ Insurance Company Security National Insurance Company 40638159 1 17/10 GL AN UMB WC IME/LHR I Nina Lautenschlagez 1 3/1/2018 12:99:36 PM (PST) I Page 11 of 11