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Insurance - Robotic Sewer Solutions, Inc. - 2019-02-27 (2)1 ® ACUR" CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DD/YYYY) 2/27/2019 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 Bolton & Company CONTACT NAME: A/CNNo Ext): 626 799-7000 Fvc No): (626)583-2117 3475 E. Foothill Blvd., Suite 100 Pasadena, CA 91107 E-MAIL ADDRESS: INSURERS AFFORDING COVERAGE NAIC # INSURER A: James River Insurance Company 12203 www.boltonco.com 0008309 INSURED Robotic Sewer Solutions, Inc. 2722 Foothill Blvd. INSURER B: StarStone Specialty Insurance Company..., 44776 INSURER C: State Compensation Insurance Fund/ INSURER D: La Crescenta CA 91214 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: 47265135 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. INSRPOLICY LTR TYPE OF INSURANCE IVSD WVO SUER POLICY NUMBER EFF MM/DD//YYYY POLICY EXP MM DD/YYYY LIMITS A v/ COMMERCIAL GENERAL LIABILITY ✓ 000506278 11/22/2018 11/22/2019 EACH OCCURRENCE $1,000,000 CLAIMS -MADE ✓ OCCUR DAMAGE TO RENTED PREMISES Ea occurrence $50,000 MED EXP (Any one person) $ 1,000 ✓ Per Project Aggregate ✓ Capped at $5,000,000 PERSONAL & ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 POLICY ✓❑ JECT 7 LOC PRODUCTS - COMP/OP AGG $ 2,000,000 $ OTHER: AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ Ea accident BODILY INJURY (Per person) $ ANY AUTO OWNED SCHEDULED AUTOS ONLY AUTOS BODILY INJURY (Per accident) $ PROPERTY DAMAGE $ Per accident HIRED NON -OWNED AUTOS ONLY AUTOS ONLY B UMBRELLA LIAB ,/ OCCUR 8744611185ALI 11/22/2018 11/22/2019 EACH OCCURRENCE $4,000,000 AGGREGATE $4000,000 ✓ EXCESS LIAB CLAIMS -MADE DED ✓ RETENTION $0 $ C WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANYPROPRIETOR/PARTNER/EXECUTIVE Y / N OFFICER/MEM BER EXCLUDED? �Y NIA ✓ 1980264 11/22/2018 11/22/2019 ✓ PER STATUTE OERH E.L. EACH ACCIDENT $ $1,000,000 (Mandatory in NH) E.L. DISEASE - EA EMPLOYEE $$1,000,000 If yes, describe under DESCRIPTION OF OPERAT!ONS below E.L, DISEASE - POLICY LIMIT $$1,000,000 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. CERTIFICATE HOLDER __..___.., "*lam CANCELLATION #314 Grade 5 Repairs Phase 7 0Costa Mesa Sanitary District rY SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE fl{� 290 Paularino Avenue MAR p 4 U 1 THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Costa Mesa, CA 92626 ACCORDANCE WITH THE POLICY PROVISIONS. coga Mesa sanit � � 191 AUTHORIZED REPRESENTATIVE --- David Kuo ACORD 25 (2016/03) ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD 47265135 1 ROBOSEW-01 1 18-19 GL, XS & WC, 18-19 1 Mary Massinger 12/27/2019 12:14:12 PM (PST) I Page 1 of 4 000506278 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ENDORSEMENTPRIMARY AND NON CONTRIBUTORY This endorsement modifies insurance provided under the following: ALL COVERAGE PARTS Name Of Additional Insured Person(s) Or Oraanization(s): Where Required By Written Contract or Agreement If no entry appears above, this endorsement applies to all Additional Insureds covered under this policy. 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 47265135 1 ROBOSEW-01 1 18-19 GL, XS & WC, 18-19 1 Mary Massinger 1 2/27/2019 12:14:12 PM (PST) I Page 4 of 4 POLICY NUMBER: 000506278 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 Organ ization(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 47265135 1 ROBOSEW-01 1 18-19 GL, XS & WC, 18-19 1 Mary Massinger 1 2/27/2019 12:14:12 PM (PST) I Page 3 of 4 POLICY NUMBER: 000506278 COMMERCIAL GENERAL LIABILITY CG 20 10 07 04 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - OWNERS, LESSEES OR This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Name of Additional Insured Person(s) or Organ ization(s): 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 11 — 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 47265135 1 ROBOSEW-01 1 18-19 GL, XS & WC, 18-19 1 Mary Massinger 1 2/27/2019 12:14:12 PM (PST) 1 Page 2 of 4 Page 1 of 1 ACCiR 1 0 CC) CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DD/YYYY) 2/27/2019 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 Bolton & Company 3475 E. Foothill Blvd., Suite 100 Pasadena, CA 91107 www.boltonco.com 0008309 CONTACT NAME: A/C No Ext): 626 799-7000 q/C No : 626 583-2117 E-MAIL ADDRESS: INSURERS AFFORDING COVERAGE NAIC # INSURER A: James River Insurance Company 12203 INSURED Robotic Sewer Solutions, Inc. 2722 Foothill Blvd. La Crescenta CA 91214 INSURER B: StarStone Specialty Insurance Company," 44776 INSURER C: State Compensation Insurance Fund INSURER D: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: 47265136 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 OF INSURANCE ADDLSUBRPOLICTYPE IVSD WVD POLICY NUMBER EFF MM DDY /YYYY POLICY EXP MM DD/YYYY LIMITS A ✓ COMMERCIAL GENERAL LIABILITY ✓ 000506278 11/22/2018 11 /22/2019 EACH OCCURRENCE $1,000,000 _7RENTECLAIMS-MADE �✓ OCCUR DAMAGE TO PREM SES (Ea occurrence) $50,000 MED EXP (Any one person) $1,000 ✓ Per Project Aggregate ✓ Capped at $5,000,000 PERSONAL & ADV INJURY $1,000,000 GEN'LAGGREGATE LIMIT APPLIESPER: GENERAL AGGREGATE $2,000,000 POLICY ✓1 JE LOC PRODUCTS -COMP/OP AGG $ 2,000 OOO $ OTHER: AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ Ea accident BODILY INJURY (Per person) $ ANY AUTO OWNEDSCHEDULED AUTOS ONLY AUTOS BODILY INJURY (Per accident) $ PROPERTY DAMAGE $ Per accident HIRED NON -OWNED AUTOS ONLY AUTOS ONLY B UMBRELLA LIAB ,/ OCCUR 87446H185ALI 11/22/2018 11/22/2019 EACH OCCURRENCE $4,000,000 AGGREGATE $4,000,000 ✓ EXCESS LIAB CLAIMS -MADE DED ✓ I RETENTION $0 $ C WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANYPROPRIETOR/PARTNER/EXECUTIVE Y / N OFFICER/MEMBER EXCLUDED? Y I N/A 1980264 11/22/2018 11/22/2019�/ SPERTATUTE OERH E.L. EACH ACCIDENT $ $1,000,000 (Mandatory in NH) E.L. DISEASE - EA EMPLOYEE $ 1 ,000,000 E.L. DISEASE - POLICY LIMIT $$1,000,000 If yes, describe under DESCRIPTION OF OPERATIONS belovv DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) GL Additional Insured applies per CG20120509 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. PFcF VFD CERTIFICATE HOLDER . . . n A' ® ')niQ CANCELLATION Costa Mesa Sanitary District 290 a Mesa ino Avenue Costa Mesa CA entre Costs Mesa Sanitary tstrlet -9t 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 David Kuo ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD 47265136 1 ROBOSEW-01 1 18-19 GL, XS & WC, 18-19 1 Mary Massinger 1 2/27/2019 12:14:12 PM (PST) I Page 1 of 2 POLICY NUMBER: 000506278 COMMERCIAL GENERAL LIABILITY CG 20 12 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 Or Political Subdivision: The Costa Mesa Sanitary District, it's elected and appointed officials, agents, officers, volunteers and employees 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 in- clude as an insured any state or governmental agen- cy or subdivision or political subdivision shown in the Schedule, subject to the following provisions: 1. This insurance applies only with respect to opera- tions performed by you or on your behalf for which the state or governmental agency or subdivision or political subdivision has issued a permit or author- ization. CG 20 12 05 09 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". © Insurance Services Office, Inc., 2008 47265136 1 ROBOSEW-01 1 18-19 GL, XS & WC, 18-19 1 Mary Massinger 1 2/27/2019 12:14:12 PM (PST) I Page 2 of 2 Page 1 of 1