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Insurance - Robotic Sewer Solutions Inc. - 2019-11-21ACOR" CERTIFICATE OF LIABILITY INSURANCE DATE (MM/°D/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 & Company NAME: 3475 E. Foothill Blvd., Suite 100 Pasadena, CA 91107 PHONE N Ext): 626 799-7000 Fvc No : 626 583-2117 EMAIL ADDRESS: INSURER(S) AFFORDING COVERAGE NAIC # wsURERA: James River Insurance Company i 12203 www.boltonco.com 0008309 INSURED Robotic Sewer Solutions, Inc. 2722 Foothill Blvd. INSURER B: StarStone Specialty Insurance Company -+_44776_ INSURER State Compensation Insurance Fund INSURER D: La Crescenta CA 91214 INSURER E: I INSURER F: C WORKERS COMPENSATION✓ 1980264 11/22/20191 11/22/2020 j I1 PER COVERAGES CERTIFICATE NUMBER: 52548916 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 ADDL SUBR POLICY EFF ! POLICY EXP LTR TYPE OF INSURANCE ! INSDI WVD 1POLICY NUMBER MM/DD/YYYY MM/DDIYYYYI LIMITS A ✓ COMMERCIAL GENERAL LIABILITY ✓ 1000506279 11/22/2019111/22/2020 1 EACH OCCURRENCE $ 1,000,000 David Kuo 7_7 CLAIMS DAMAGE TO RENTED -MADE ✓ I OCCUR PREMISES (Ea occurrence) $ 50,000 �✓ . Per Project Aggregate I I MED EXP (Any one person) $1,000 Capped at $5,000,000 j PERSONAL &ADV INJURY$1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: ! GENERAL AGGREGATE ( $2,000,000 POLICY ,� JE LOC PRODUCTS - COMP/OP AGG ( $ 2,000,000 OTHER: i C $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT j � Ea accident � $ _ ANY AUTO BODILY INJURY (Per person) $ OWNED SCHEDULED BODILY INJURY (Per accident) j $ AUTOS ONLY AUTOS HIRED NON -OWNED PROPERTY DAMAGE $ AUTOS ONLY AUTOS ONLY Per accident $ B UMBRELLA LIAB t �/ OCCUR I 8744611196ALI 1 11/22/2019 11/22/2020 1 EACH OCCURRENCE $4,000,000 ✓ j EXCESSUAB ;CLAIMS -MADE! ! AGGREGATE $4,000,000 I DED I ✓ RETENTION $ 0 ( $ C WORKERS COMPENSATION✓ 1980264 11/22/20191 11/22/2020 j I1 PER AND EMPLOYERS' LIABILITY �/ STATUTE EORH Y/N ANYPROPRIETOR/PARTNER/EXECUTIVE j E.L. EACH ACCIDENT $ $1,000,000 OFFICER/MEMBER EXCLUDED? FYN ! A (Mandatory in NH) E.L. DISEASE EMPLOYEE $ si 000,000 _-EA If yes, describe under ! DESCRIPTION OF OPERATIONS 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 CANCELLATION #314 Grade 5 Repairs Phase 7 Costa Mesa Sanitary District Y 290 Paularino Avenue \a Costa Mesa, CA 92626 l 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 52548916 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 1 of 4 POLICY NUMBER: 000506279 COMMERCIAL GENERAL LIABILITY CG 20 10 07 04 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED — OWNERS,OR CONTRACTORS - SCHEDULED PERSON OR ORGANIZATION This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART Name Of Additional Insured Person(s) Or Organization (s): Locations Of Covered Operations Where required by written contract or written agreement All operations of the Named Insureds 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 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- sions apply: This insurance does not apply to "bodily injury" or "property damage" occurring after: 1. All work, including materials, parts 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 oth- er than another contractor or subcontractor engaged in performing operations for a princi- pal as a part of the same project. © ISO Properties, Inc., 2004 52548916 1 ROBOSEW-01 1 19-20 GL, XS & WC, 19-20 1 Victor Morales 1 11/21/2019 3:50:32 PM (PST) ( Page 2 of 4 Page 1 of 1 ❑ POLICY NUMBER: 000506279 COMMERCIAL GENERAL LIABILITY CG 20 37 07 04 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Name Of Additional Insured Person(s) Or Organization (s): Location And Description Of Completed Opera - tions Where required by written contract or written All operations of the Named Insureds agreement 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 organiza- tions) 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 desig- nated and described in the schedule of this endorse- ment 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 52548916 ( ROBOSEW-01 1 19-20 GL, XS & WC, 19-20 1 Victor Morales 1 11/21/2019 3:50:32 PM (PST) I Page 3 of 4 000506279 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. PRIMARY AND NON CONTRIBUTORY ENDORSEMENT 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 IIf 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 52548916 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 4 of 4