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Insurance - Robotic Sewer Solutions, Inc. 2019-11-21AcoR CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, 11/21/2019 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). PRODUCERCONTACT Bolton & Corn an NAME: 3475 E. Foothill Brvd., Suite 100 Pasadena, CA 91107 PHONE I Ext : 626 799-7000 arc No : 626 583-2117 ( A �o ADDRESS: INSURER(S) AFFORDING COVERAGE NAIC # PRODUCTS - COMP/OP AGG $ 2,000,000 _ INSURER A: James River Insurance Company 12203 www.boltonco.com 0008309 _ INSURED Robotic Sewer Solutions, Inc. 2722 Foothill Blvd. INSURER B: StarStone Specialty Insurance CpTp@ny 44776 _ INSURER C : State Compensation Insurance Fund - INSURER D: La Crescenta CA 91214 INSURER E: HIRED NON -OWNED AUTOS ONLY _� AUTOS ONLY ( PROPERTY DAMAGE $ Per accident _ INSURER F: COVERAGES CFRTIFICATF NIIMRFR• A,9AAJQQ17 RFVIQIf1N NIIMRt=R• 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 ADDL SUERPOLICY LTR TYPE OF INSURANCE POLICY NUMBER EFF POLICY EXP MM/DDNYYY MM/DDNYYY LIMITS A ✓ j COMMERCIAL GENERAL LIABILITY 1000506279 1 11/22/2019 11/22/2020 ! EACH OCCURRENCE $1,000,000 CLAIMS -MADE OCCUR DAMAGE TO RENTED PREMISES Ea occurrence $ 50,000 Per Project Aggregate MED EXP (Any one person) $ 1,000 _ Capped at $5,000,000 PERSONAL & ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: _ GENERAL AGGREGATE $ 2,000,000 POLICY ✓ PE a LOC PRODUCTS - COMP/OP AGG $ 2,000,000 , OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ (Ea accident) r ANY AUTO BODILY INJURY (Per person) $ !OWNED 17-1, SCHEDULED I AUTOS ONLY AUTOS C BODILY INJURY (Per accident) $ HIRED NON -OWNED AUTOS ONLY _� AUTOS ONLY ( PROPERTY DAMAGE $ Per accident _ B UMBRELLALIAB OCCUR `8744611196AL1 i 11/22/2019 111/22/2020 EACH OCCURRENCE $4,000,000 �✓ 1 EXCESS LIAB CLAIMS -MADE. j AGGREGATE $ 4,000,000 DED I ✓ RETENTION $O I i _ 1 $ C WORKERS COMPENSATION I 1980264 11/22/2019 11/22/2020. PER 0TH- ! STATUTE EMPLOYERS' LIABILITY Y / N ER IAND ANYPROPRIETOR/PARTNER/EXECUTIVEi OFFICER/MEMBER EXCLUDED? ❑Y N / A E.L. EACH ACCIDENT $$ 1000,000 (Mandatory in NH) ! E.L. DISEASE - EA EMPLOYEE, $ $1.000.000 If yes, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT 1 $ $1,000,000 ! ( i DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) GL Additional Insured applies per CG20120413 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. lrtK 1 It-IUA 1 t NULUtK UANGELLATIDN Costa Mesa Sanitary District 290 Paularino Avenue Costa Mesa CA 92626 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 52548917 I ROBOSEW-01 1 19-20 GL, XS & WC, 19-20 1 Victor Morales 1 11/21/2019 3:50:32 PM (PST) I Page 1 of 2 POLICY NUMBER:000506279 COMMERCIAL GENERAL LIABILITY CG 20 12 04 13 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: Any State or Governmental Agency or Subdivision or Political Subdivision for whom during the policy period you and such State Or Governmental Agency or Subdivision or Political Subdivision have agreed in writing in a contract or agreement that such State Or Governmental Agency or Subdivision Or Political Subdivision be added as an additonal insured on your policy. 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. CG 20 12 04 13 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 shall not increase the applicable Limits of Insurance shown in the Declarations. © Insurance Services Office, Inc., 2012 52548917 1 ROBOSEW-01 1 19-20 GL, XS & WC, 19-20 1 Victor Morales 1 11/21/2019 3:50:32 PM (PST) I Page 2 of 2 Page 1 of 1