Insurance - ADS LLC 2019-10-01AICOR�0
`..+�" CERTIFICATE OF LIABILITY INSURANCE
DATE 19 YYYY)
10/01/20/2019
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
MARSH USA INC.
540 W. MADISON
CONTACT
NAME'
A/CNE. No Ext): A/C No):
CHICAGO, IL 60661
Attn: Fax: 212-948-0770 or Chicago. CertRequest@marsh.com
ADDRESS:
01/01/2019 01/01/2020
(
EACH OCCURRENCE $ 2,000,000
INSURER(S) AFFORDING COVERAGE NAIC #
INSURER A: Liberty Mutual Fire Insurance Company 23035
INSURED
ADS LLC
INSURER B: N/A N/A
INSURER C : Liberty Insurance Corporation 42404
340 The Bridge Street, Suite 204
HUNTSVILLE, AL 35806
INSURER D:
INSURER E: j
PRODUCTS - COMP/OP AGG $ 4,000,000
INSURER F:
COVERAGES CERTIFICATE NUMBER: CHI -009336582-04 REVISION NUMBER: 8
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.
I
LTR
I TYPE OF INSURANCE
AN D WV
POLICY NUMBER
EFF _#ouCY EXP
MM DDPOLICY/YYYY MM DD/YYYY
LIMITS
A
X COMMERCIAL GENERAL LIABILITY
CLAIMS -MADE OCCUR
X
TB2-681-004088-049
01/01/2019 01/01/2020
(
EACH OCCURRENCE $ 2,000,000
DAMAGE TO RENTED 1,000,000
PREMISES Ea occurrence $
MED EXP (Any one person) $ 10,000
!
i
i
GGEEN'L AGGREGATE LIMIT APPLIES PER:
X POLICY JE LOC
PERSONAL &ADV INJURY $ 2,000,000
GENERAL AGGREGATE $ 4,000,000
PRODUCTS - COMP/OP AGG $ 4,000,000
$
I OTHER:
A
AUTOMOBILE
LIABILITY
AS2-681-004088-039
01/01/2019 01/01/2020
COMBINED SINGLE LIMIT $ 2,000,000
Ea accident
BODILY INJURY (Per person) $
X
ANY AUTO
X
OWNED SCHEDULED
AUTOS ONLY AUTOS
I
I
i
BODILY INJURY (Per accident)! $
X
HIRED I X NON -OWNED
AUTOS ONLY AUTOS ONLY
!
PROPERTY DAMAGE $
Per accident
$
UMBRELLA LIAR I OCCUR
I
EACH OCCURRENCE $
EXCESS LIAB CLAIMS -MADE
j
(AGGREGATE $
$
DED RETENTION $
I
C
C
WORKERS COMPENSATION
AND EMPLOYERS' LIABILITY
ANYPROPRIETOR/PARTNER/EXECUTIVE Y / N
OFFICER/MEMBER EXCLUDED? ❑N
(Mandatory in NH)
I N / A I
WA7-68D-004088-519 (AOS)
I
( WC7-681-004088-019 (WI,OR)
01/01/2019 101/01/2020
01/01/2019 01/01/2020
X PER OTH-
STATUTE ER
E.L. EACH ACCIDENT $ 2,000,000
E.L. DISEASE - EA EMPLOYEEI $ 2,000,000
If yes, describe under
DESCRIPTION OF OPERATIONS below
I
E.L. DISEASE - POLICY LIMIT 1 $ 2,000,000
DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required)
Costa Mesa Sanitary District is included as Additional Insured with respect to General and Automobile Liability coverages as required by written contract, subject to policy terms and conditions. This insurance is
Primary and Non -Contributory over any existing insurance and limited to liability arising out of the operations of the Named Insured and where required by written contract. Waiver of Subrogation is applicable where
required by written contract.
CERTIFICATE HOLDER CANCELLATION
Costa Mesa Sanitary District SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
250 Paularino Avenue THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
Costa Mesa, CA 9262611F?
ACCORDANCE WITH THE POLICY PROVISIONS.
AUTHORIZED REPRESENTATIVE
of Marsh USA Inc.
Manashi Mukherjee ...r,�+toestw:e ntra-c.e
@ 1988-2016 ACORD CORPORATION. All rights reserved.
ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD
Policy Number TB2-601-004088-048
Issued by Liberty Mutual Fire Insurance Company
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ |TCAREFULLY.
Change Endorsement
Named Insured Endorsement number
IDEX Corporation 009
The following changes are effective as of the effective dates shown below and will terminate with the policy. All
other provisions of the policy remain unchanged.
Change Description
Effective Date: 08V12/2018
Additional Insured — State [rGovernmental Agency Or SubdiviaionOrpu|itice|Subdiviekon—PennityOr
AuthorizaUnns, Form CG 20 1204 13, added per Endorsement number OO8. Effective 09/12/2019. |nauad on
Issued: 10/01/2019 JJS
IC 99 99 07 09 @ 2008, Liberty Mutual Group of Companies. All rights reserved. Page 1 of 1
POLICY NUMBER: TB2-681-004088-049 COMMERCIAL GENERAL LIABILITY
CG 20 12 0413
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:
Costa Mesa Sanitary District
I 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 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.
However:
a. The insurance afforded to such additional
insured only applies to the extent permitted
by law; and
b. 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.
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".
B. 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
2. Available under the applicable Limits of
Insurance shown in the Declarations;
whichever is less.
This endorsement
applicable Limits of
Declarations.
shall not increase the
Insurance shown in the
CG 20 12 0413 ® Insurance Services Office, Inc., 2012 Page 1 of 1