Insurance - C & R Drains - 2019-01-16ACORO°
c" CERTIFICATE OF LIABILITY INSURANCE
E
DAT(MM/MM/DD/YYYY)019
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 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
Wood Gutmann & Bogart Insurance Brokers
15901 Red Hill Ave., Suite 100
Insurance License #0679263
CONTACT
NAME: Jamie Bingham
PHONE FAX
A/c No Ext): 714-824-8380 A/C No): 714-573-1770
ADDRESS: Jamie@wgbib.com
Tustin CA 92780
INSURER(S) AFFORDING COVERAGE NAIC #
Y
INSURER A: Kinsale Insurance Company/
INSURED C&RDR-1
INSURER B: Westchester Surplus Lines
C & R Drains, Inc
1525 W. Macarthur Blvd.#11
INSURER C: ComWest Insurance Com an 12177
INSURER D:
Costa Mesa CA 92626
INSURER E:
INSURER F :
COVFRAGFS CFRTIFICATF NIIMRFR• 13A311;F,771n RFVICInKI IVIIMRGR•
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.
LTR
TYPE OF INSURANCE
IVSD
SWVD UER
POLICY NUMBER
EFF
MM/DD/YYYY
MM/DDPOLICY EXP
PY/YYYY
LIMITS
A
X COMMERCIAL GENERAL LIABILITY
Y
Y
0100064903-0
4/11/2018
4/11/2019
EACH OCCURRENCE $ 1,000,000
CLAIMS -MADE lxl OCCUR
DAMAGE TO RENTED
PREMISES Ea occurrence $ 100,000
MED EXP (Any one person) $ excluded
PERSONAL & ADV INJURY $ 1,000,000
GEN'L AGGREGATE LIMIT APPLIES PER:
PRO ❑ LOC
POLICY11 JECT
GENERAL AGGREGATE $ 2,000,000
PRODUCTS - COMP/OP AGG $ 2,000,000
$
OTHER:
AUTOMOBILE
LIABILITY
COMBINED SINGLE LIMIT $
Ea accident
BODILY INJURY (Per person) $
ANY AUTO
ALL OWNED SCHEDULED
AUTOS AUTOS
BODILY INJURY (Per accident) $
NON -OWNED
HIRED AUTOS AUTOS
PROPERTY DAMAGE
Per accident $
UMBRELLA LIAB
OCCUR
EACH OCCURRENCE $
AGGREGATE $
EXCESS LIAB
CLAIMS -MADE
DED RETENTION $
$
C
WORKERS COMPENSATION
AND EMPLOYERS' LIABILITY Y / N
WCV5502648
9/10/2018
9/10/2019
X PER OTH-
STATUTE ER
E.L. EACH ACCIDENT $ 1,000,000
ANY PROPRIETOR/PARTNER/EXECUTIVE
OFFICER/MEMBER EXCLUDED?
N / A
E.L. DISEASE - EA EMPLOYEE $ 1,000,000
(Mandatory in NH)
If yes, describe under
DESCRIPTION OF OPERATIONS below
E.L. DISEASE - POLICY LIMIT $ 1,000,000
B
Pollution Liability
G71117200001
4/11/2018
4/11/2019
Aggregate Limit $2,000,000
Deductible $2,500
DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required)
Certificate holder is named as additional insured per the attached endorsements as required by written contract and subject to the terms & conditions of the
policy:
GL Additional Insured per Form CG20120509
GL 30 -day Notice of Cancellation per Form ADF9027 0418
GL Waiver of Subrogation per Form CAS4008 0110
GL Primary & Non -Contributory per Form CAS5001 0717
CFRTIFICATF Hnl IFR renlr-1=1 I ATIr)N
U 1988-2014 ACORD CORPORATION. All rights reserved
ACORD 25 (2014101) The ACORD name and logo are registered marks of ACORD
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
Costa Mesa Sanitary District _9V
290 Paularino V
r
ACCORDANCE WITH THE POLICY PROVISIONS.
AUTHORIZED REPRESENTATIVE
Costa Mesa CA 92626
U 1988-2014 ACORD CORPORATION. All rights reserved
ACORD 25 (2014101) The ACORD name and logo are registered marks of ACORD
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
SCHEDULE ADDITIONAL INSURED - PRIMARY AND NON-CONTRIBUTORY
Attached To and Forming Part of Policy
Effective Date of Endorsement
Named Insured
0100064903-0
05/24/2018 12:01AM at the Named Insured
C & R Drains Inc
address shown on the Declarations
Additional Premium:
Return Premium:
$0
$0
Policy Change Number: 1
This endorsement modifies insurance provided under the following:
COMMERCIAL GENERAL LIABILITY COVERAGE
PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE
SCHEDULE
Name and Address of Additional Insured Person(s) or Organization(s):
Costa Mesa Sanitary District, 290 Paularino Avenue, Costa Mesa CA 92626
A. SECTION II- WHO IS AN INSURED is amended to include any person or organization shown in the above Schedule as an
Additional Insured but only for the vicarious liability imposed on the Additional Insured provided that such liability is
caused by the sole negligent conduct of the Named Insured and is proximately caused by "your work" or "your
product" for the Additional Insured.
B. The insurance provided to the Additional Insured under this endorsement is limited as follows:
1. The insurance provided to the Additional Insured shall be excess with respect to any other valid and collectible
insurance available to the Additional Insured unless the written contract specifically requires that this insurance
apply on a primary and non-contributory basis, in which case this insurance shall be primary and non-contributory.
2. In the event the written contract requires Limits of Insurance in excess of the Limits of Insurance provided by this
policy, the Limits of Insurance provided by this policy shall apply and not the limits required by the written
contract. This endorsement shall not increase the Limits of Insurance stated in the Declarations of this policy.
3. This insurance does not apply to "bodily injury" or "property damage" arising out of "your work or "your product"
included in the "products -completed operations hazard" unless you are required to provide such insurance by
written contract. If required, then insurance is provided only for "bodily injury" or "property damage" that occurs
during the policy period arising out of "your work" or "your product".
4. Where there is no duty to defend the Named Insured, there is no duty to defend the Additional Insured. Where
there is no duty to indemnify the Named Insured, there is no duty to indemnify the Additional Insured.
5. This insurance does not apply to "bodily injury" or "property damage" arising out of:
a. The sole negligence of the Additional Insured or any employee of the Additional Insured; or
b. Any obligation of the Additional Insured to indemnify another because of damages arising out of such injury or
damage.
C. Duties of the Additional Insured in the event of "occurrence", claim or "suit":
1. The Additional Insured must promptly give notice of an "occurrence", a claim which is made or a "suit", to any
other insurer which has insurance for a loss to which this insurance may apply.
CAS50010717 Page 1 of 2
2. The Additional Insured must promptly tender the defense of any claim made or "suit " to any other insurer which
also issued insurance to the Additional Insured as a Named Insured or to which the Additional Insured may qualify
as an Additional Insured for a loss to which this insurance may apply.
ALL OTHER TERMS AND CONDITIONS OF THE POLICY REMAIN UNCHANGED.
CAS5001 0717 Page 2 of 2
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
ADDITIONAL INSURED - STATE OR GOVERNMENTAL
AGENCY OR SUBDIVISION OR POLITICAL
SUBDIVISION - PERMITS OR AUTHORIZATIONS
Attached To and Forming Part of Policy
Effective Date of Endorsement
Named Insured
0100064903-0
05/24/2018 12:01AM at the Named Insured
C & R Drains Inc
address shown on the Declarations
Additional Premium:
Return Premium:
$0
$0
Policy Change Number: 1
This endorsement modifies insurance provided under the following:
COMMERCIAL GENERAL LIABILITY COVERAGE PART
SCHEDULE
State or Governmental Agency or Subdivision or 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 II —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".
ALL OTHER TERMS AND CONDITIONS OF THE POLICY REMAIN UNCHANGED.
CG 20 12 05 09 0 Insurance Services Office, Inc., 2008
Page 1 of 1
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
POLICY TERMINATION NOTICE TO THIRD PARTY
Attached To and Forming Part of Policy
Effective Date of Endorsement
Named Insured
0100064903-0
05/24/2018 12:01AM at the Named Insured
C & R Drains Inc
address shown on the Declarations
Additional Premium:
Return Premium:
$0
$0
Policy Change Number: 1
This endorsement modifies insurance provided under the following:
ALL COVERAGE FORMS
The CANCELLATION section of the CONDITIONS section of this Policy are amended by adding the following:
SCHEDULE
Notice of Policy Termination To:
Costa Mesa Sanitary District, 290 Paularino Avenue, Costa Mesa CA 92626
If we send notice of termination of this policy to the insured, we will also send written notification of such termination to
the person or organization shown in the Schedule above at the address shown above. We will mail this notice in
accordance with the Cancellation and Nonrenewal terms and conditions of this policy. If notice is mailed, proof of mailing
will be sufficient proof of notice.
No policy rights are conferred to the person or organization shown in the Schedule above. Failure to provide notice as
described in this endorsement shall impose no obligation or liability of any kind upon the Company.
ALL OTHER TERMS AND CONDITIONS OF THE POLICY REMAIN UNCHANGED.
ADF9027 0418 Page 1 of 1
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
WAIVER OF TRANSFER OF RIGHTS OF RECOVERY AGAINST OTHER TO US
Attached To and Forming Part of Policy
Effective Date of Endorsement
Named Insured
0100064903-0
05/24/2018 12:01AM at the Named Insured
C & R Drains Inc
address shown on the Declarations
Additional Premium:
Return Premium:
$0
$0
Policy Change Number: 1
This endorsement modifies insurance provided under the following:
COMMERCIAL GENERAL LIABILITY COVERAGE
PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE
SCHEDULE
Name of Person or Organization:
Costa Mesa Sanitary District, 290 Paularino Avenue, Costa Mesa CA 92626
SECTION IV — CONDITIONS, 8. Transfer of Rights of Recovery against Others to Us is amended by the addition of the
following:
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 work" done under a written contract with that person or
organization wherein you have agreed to provide this waiver. This waiver applies only to the person or organization shown
in the Schedule above and only to the extent of written agreement.
ALL OTHER TERMS AND CONDITIONS OF THE POLICY REMAIN UNCHANGED.
CAS4008 0110 Page 1 of 1