Loading...
Insurance - GCI Construction, Inc. Workers Comp. - Pollution 2018-03-01I ® af AC"RCERTIFICATE OF LIABILITY INSURANCE 11.�' DATE(MMIDDNYYY) 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). PRODUCERCom PassCONTACT Direct Insurance Services, Inc.InD. 13681 Newport Ave., Ste 8 #622 Tustin, CA 92780 NAME: Jeremy Seltzer PHONE 714-665-9800 C'No: 714-665-9801 E-MAIL ADDRESS: 'erem Cdisi.CAm INSURER(S) AFFORDING COVERAGE MAIC# �/ INSURER A: Great American Assurance Company 26344 www.odisi.com License #OH16100 INSURED GCI Construction, Inc. 1031 Calle Recodo, Ste. D San Clemente CA 92673 INSURER B: Wesco Insurance Company 25011 INSURERC: Insurance Company of the West 27847 INSURER D: RSUI Indemnity Company 22314 INSURER E: AGCS Marine Insurance Company 22837 MED EXP (Any one Person) $Excluded INSURE.': Westchester Surplus Lines Insurance Cor 1 10172 COVERAGES CERTIFICATE NUMBER: 40638163 REVISIUN NUMt$EK: 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. INS. LTR TYPE OF INSURANCE iNgn wyn SUER POLICY NUMBER EFFE%P MMIDDYIYYYY MMIDD LIMITS A Costa Mesa Sanitary DisMct COMMERCVILGENERAL LIABILITY CLAIMS -MADE OCCUR `/ �/ GLP 1552541 ¢/1/2017 ¢/1/2016 EACH OCCURRENCE $1000000 1/ DAMA E 0RENTED PREMISES Ea oCCU nce $50000 ✓ MED EXP (Any one Person) $Excluded Owner's/Cont. Pro XCU/Deductible$5000 PERSONAL&ADV INJURY $1,000000 AGGREGATE LIMIT APPLIES PER: GENERALAGGREGATE $2,000,000 GENT PRODUCTS - COMP/OP AGO $2000,000 POLICY ✓JET LOC Employee Benifits $1,000,000 OTHER: B AUTOMOBILE LIABILITY ✓ ✓ WPP151620100 4/1/2017 4/1/2018 COMBINED SINGLE LIMIT $ Ea accident 1,000,000 BODILY INJURY (Per person) $ ✓ ANY AUTO BODILY INJURY (Per accident) $ OWNED SCHEDULED AUTOS ONLY AUTOS HIRED NON -OWNED ✓ AUTOS ONLY ✓ AUTOS ONLY Comp/Coll Ded$1,000 PROPERTY DAMAGE $ Per accident $ No Liabilit Deductible D �/ UMBRELLA LIAB ,/ OCCUR ,/ NHA242287 4/1/2017 4/1/2018 EACH OCCURRENCE $¢000000 AGGREGATE $4,000,000 EXCESS LIAB C1AIMS-MADE $0 Deductible OED I I RETENTION$ 1 1 $ C WORKERS COMPENSATION AND EMPLOYERS' LIABILITY YIN ANYPROPRIETOWPARTNEWEXECUTIVE ✓ WSA5040042 3/17/2018 3/17/2019 ,/ STATUTE I I 'ERT' - E.L. EACH ACCIDENT $1000000 E.L. DISEASE - EA EMPLOYEE $ 1.000.000 OFFICERIMEMBEREXCLUDED? (Mandatory In NH) If yes, describe under DESCRIPTION OF OPERATIONSbal. NIA $O Deductible E.L. DISEASE- POLICY LIMIT $1000000 E fF IM-Eqp./Lesd-Hrd-R Pollution MXI 93 076 269 G4686643.5001 4/1/2017 2/2/2018 4/1/2018 2/2/2019 Sch/Per:481K/100K Deductible $1,000 $2,000,000/$2,000,000 DESCRIPTION OF OPERATIONS/ LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, maybe attached if more space is required) Project No. 316 Costa Mesa Sanitary District GCI Job No. 502 DISTRICT, and its officers, officials, employees, and volunteers, are named as additional insured as per the attached endorsements with respects to the operations of the named insured as per contract. un. non rANrPI I ATinN ...-,..,..--._...,_.._.. .. Project No. 316 Costa Mesa Sanitary District G . M "Ito ------ - SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Costa Mesa Sanitary District 1 O THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 2 290 Paularino Avenue MAR 2�1U ACCORDANCE WITH THE POLICY PROVISIONS. Costa Mesa CA 92626 AUTHORUED REPRESENTATIVE \ ` .1•G. �((��j✓�(�y� �+� .. Jt Costa Mesa Sanitary DisMct V Jeremy Seltzer U 1968-ZUIO AGUKU uuKYURAIIVIN. All rights ACORD 25 (2016103) The ACORD name and logo are registered marks of ACORD 90638163 1 17/18 GL AU UMB WC IME/LHR I Nina Lautenschlagem 1 3/1/2018 12;99;36 PM (PST) I Page 1 of 10 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 40638163 1 17/18 GL AO NAB WC IME/LNR I Nii La tenschlagem 1 3/1/2018 12:49:36 PM (PST) I Page 2 of 10 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 Ization(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 Certificatels) 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 persons) 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) 40638163 1 17/18 GL AU MB WC IM6/LHR I Nina LauCenschlagei 1 3/1/2018 12:49:36 PM (PST) I Page 3 of 10 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 S. 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) 40638163 11]/18 GL AU OMB WC IME/LHR I Nina Lauten6chlagei 13/1/2010 12:49:36 PM (PST) I Page 4 of 10 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 40638163 1 17/18 GL A OMB WC IM/LHR I Nina Lautenschlagec 1 3/1/2018 12:49:36 PM (PST) I Page 5 of 10 Great 1Americ n Assurance Company 552541 GCI Construction, Inc. CG 25 03 (Ed 03 97) THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. DESIGNATED CONSTRUCTION PROJECTIS) GENERAL AGGREGATE LIMIT This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Designated Construction Projects: 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) 90630163 1 17/18 GL AU OMB WC IME/LHR I Nies LauCenschlage, 1 3/1/2018 12:99:36 PM (PST) I Page 6 of 10 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: 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) 90638163 1 17/18 GL A MB WC IME/LNR I Nina Lautenachlage[ 1 3/1/2018 12:99:36 PM (PST) I Page 7 of 10 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: �3W ) Authorized Re resentative Named Insured: GCI Construction, Inc. 6Ia:f:1 111" 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 ❑ 40638163 1 17/18 GL AU U WC IME/LHR I Nina La tenschlagex 1 3/1/3018 12:49:36 PM (PST) j Page 8 of 10 WPP1516201 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 ❑ 40638163 117/18 GL AU U WC IME/LHR I Nies Lautenschlagei 13/1/2018 12:49:36 PN (PST) I Page 9 of 10 COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 04 03 O6 (Ed. 484) 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 Any person or organization as required by written contract .fob Description 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 40638163 1 17/18 GL Sn NAB WC IME/LHR I Nina Lau[enschlagei 1 3/1/2018 12:49:36 PM (PST) I Page 10 of 10