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Insurance - GCI Construction, Inc. - 2020-04-13ACOR" CERTIFICATE OF LIABILITY INSURANCE 1 DATE (MM/DD/YYYY) Ilkl� 4/13/2020 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). PRODUCERCompass Direct Insurance Services, Inc. 13681 Newport Ave., Ste 8 #622 Tustin, CA 92780 NAME: Jeremy Seltzer PHONE (A/C. N Ext): 714-665-9800 Arc No : 714-665-9801 E-MAIL ADDRESS: 'erem cdisi.com INSURER(S) AFFORDING COVERAGE NAIC # NPC -1003310-00 INSURER A: Greenwich Insurance Company 22322 www.cdisi.com License #OH16100 INSURED GCI Construction, Inc. 1031 Calle Recodo, Ste. D INSURER B: Everest National Insurance Company 10120 INSURER C : Westchester Surplus Lines Insurance Co 10172 INSURER D: San Clemente CA 92673 INSURER E: INSURER F : DAMAGE TO RENTED PREMISES Ea occurrence $ 50,000 COVERAGES CERTIFICATE NUMBER: 55056156 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 TYPE OF INSURANCE ADDL IN SUBR WVD POLICY NUMBER POLICY EFF MM/DD/YYYY POLICY EXP MM/DD/YYYY LIMITS A ✓ COMMERCIAL GENERAL LIABILITY ✓ ✓ NPC -1003310-00 4/1/2020 4/1/2021 EACH OCCURRENCE $1,000,000 CLAIMS -MADE ✓ OCCUR DAMAGE TO RENTED PREMISES Ea occurrence $ 50,000 MED EXP (Any one person) $ Excluded ✓ Owner's/Cont. Pro ✓ XCU/Deductible $5,000 PERSONAL & ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 j PRO - POLICY FV] JEC E LOC PRODUCTS - COMP/OP AGG $ 2,000,000 to ee Benifits $1,000,000 OTHER:Em A AUTOMOBILE LIABILITY✓ ✓ NBA -1003312-00 4/1/2020 4/1/2021 LIMIT $ 1,000,000 Ea accident) BODILY INJURY (Per person) $ ✓ ANY AUTO OWNED SCHEDULED AUTOS ONLY AUTOS BODILY INJURY (Per accident) $ ✓ HIRED NON -OWNED AUTOS ONLY ✓ AUTOS ONLY Comp/Coll Ded $1,000 PROPERTY DAMAGE $ Per accident $ No LiabilitV Deductible A ✓ UMBRELLA LIAB �/ OCCUR NEC -6006091-00 4/1/2020 4/1/2021 EACH OCCURRENCE $5,000,000 AGGREGATE $ 5,000,000 EXCESS LIAB -F CLAIMS -MADE — $0 Deductible DED I RETENTION $ $ B WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y / N ANYPROPRIETOR/PARTNER/EXECUTIVE F7 OFFICER/MEMBER EXCLUDED? N / A ✓ 7600019322191 8/1/2019 8/1/2020 �/ SPER TATUTE OERH E.L. EACH ACCIDENT $ 1,000,000 E.L. DISEASE - EA EMPLOYEE $1,000,000 (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below $0 Deductible E.L. DISEASE - POLICY LIMIT $ 1,000,000 A IM-Eqp./Lesd-Hrd-R NIM -1003311-00 4/1/2020 4/1/2021 Sch/Per:481K/100K Deductible $1,000 A BPP NIM -1003311-00 4/1/2020 4/1/2021 $100,000 Deductible $1,000 C Pollution G46866435 003 2/2/2020 2/2/2021 2,000,000 Deductible 5,000 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) Canyon Pump Station Rehabilitation and Sewer Force Main Replacement – Project No. 319 & 320 Costa Mesa Sanitary District GCI Job No. 556 The Costa Mesa Sanitary District, it's elected and appointed officials, agents, officers, volunteers and employees are additional insureds as per attached endorsements with respects to the operations of the named insured as per contract. CERTIFICATE HOLDER CANCELLATION 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 Jeremy Seltzer ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD 55056156 1 20-21 GL AU UMB WC IME/LHR I Nina Lautenschlager 1 4/13/2020 12:59:23 PM (PDT) I Page 1 of 11 Policy Number: NBA -1003312-00 A. Temporary Substitute Auto Physical Damage SECTION I — COVERED AUTOS, C. Certain Trailers, Mobile Equipment And Temporary Substitute Autos is changed by adding the following: If Physical Damage coverage is provided by this Coverage Form, the following types of vehicles are also covered "autos" for Physical Damage coverage: 1. Any "auto" you do not own while used with the permission of its owner as a temporary substitute for a covered "auto" you own that is out of service because of its: a. Breakdown; b. Repair; C. Servicing; d. "Loss"; or e. Destruction. B. Who Is An Insured SECTION II — COVERED AUTOS LIABILITY COVERAGE, A. Coverage, 1. Who Is An Insured is changed by adding the following: 1. Broad Form Insured For any covered "auto", any subsidiary, affiliate or organization, other than a partnership or joint venture, as may now exist or hereafter be constituted over which you assume active management or maintain ownership or majority interest, provided that you notify us within ninety (90) days from the date that any such subsidiary or affiliate is acquired or formed and that there is no similar insurance available to that organization. However, coverage does not apply to "bodily injury" or "property damage" that occurred before you acquired or formed the organization. 2. Employees As Insureds Any "employee" of yours is an "insured" while using a covered "auto" you don't own, hire or borrow, in your business or your personal affairs. 3. Additional Insured By Contract, Agreement Or Permit Any person or organization with whom you have agreed in writing in a contract, agreement or permit, to provide insurance such as is provided under this policy, provided that the "bodily injury" or "property damage" occurs subsequent to the execution of the written contract, agreement or permit. 4. Employee Hired Autos An "employee" of yours is an "insured" while operating an "auto" hired or rented under a contract or agreement in that "employee's" name, with your permission, while performing duties related to the conduct of your business. XIC 421 1013 © 2013 X.L. America, Inc. All Rights Reserved. May not be copied without permission. Includes copyrighted material of Insurance Services Office, Inc., with its permission. 55056156 1 20-21 GL AU UMB WC IME/LHR I Nina Lautenschlager 1 4/13/2020 12:59:23 PM (PDT) I Page 2 of 11 5. Glass Repair— Waiver Of Deductible No deductible applies to glass damage if the glass is repaired rather than replaced. F. Physical Damage Coverage Extensions SECTION 111 — PHYSICAL DAMAGE COVERAGE, A. Coverage, 4. Coverage Extensions is amended by the following: 1. Additional Transportation Expense Sections a. and b. are amended to provide a limit of $50 per day and a maximum limit of $1,000. 2. Hired Auto Physical Damage The following section is added: Any "auto" you lease, hire, rent or borrow is deemed to be a covered "auto" for physical damage coverage. The most we will pay for each covered "auto" is the lesser of: (1) the actual cash value; (2) the cost for repair or replacement; or (3) $50,000, or higher limit if shown on the Declarations for Hired Auto Physical Damage Coverage. For each covered "auto" a deductible of $100 for Comprehensive Coverage and $1,000 for Collision Coverage will apply. G. Business Auto Conditions SECTION IV — BUSINESS AUTO CONDITIONS, A. Loss Conditions is changed by the following: 1. Notice Of Occurrence Section 2. — Duties In The Event Of Accident, Claim, Suit Or, Loss, a. is changed by adding the following: If you report an injury to an "employee" to your workers' compensation carrier and if it is subsequently determined that the injury is one to which this insurance may apply, any failure to comply with this condition will be waived if you provide us with the required notice as soon thereafter as practicable after you know or reasonably should have known that this insurance may apply. 2. Waiver Of Subrogation Section 5. Transfer Of Rights Of Recovery Against Others To Us is changed by adding the following: However, this Condition does not apply to any person(s) or organization(s) with whom you have a written contract, but only to the extent that subrogation is waived prior to the "accident" or the "loss" under such contract with that person or organization. XIC 421 1013 © 2013 X.L. America, Inc. All Rights Reserved. May not be copied without permission. Includes copyrighted material of Insurance Services Office, Inc., with its permission. 55056156 1 20-21 GL AU UMB WC IME/LHR I Nina Lautenschlager 1 4/13/2020 12:59:23 PM (PDT) I Page 3 of 11 POLICY NUMBER: NPC -1003310-00 COMMERCIAL GENERAL LIABILITY CG 20 37 04 13 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY: This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE PART SCHEDULE Name Of Additional Insured Person(s) Or Organization(s) Location And Description Of Completed Operations Blanket as required by written contract. Blanket as required by written contract. 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" or "property damage" caused, in whole or in part, by "your work" at the location designated and described in the Schedule of this endorsement performed for that additional insured and included in the "products -completed operations hazard". However: 1. The insurance afforded to such additional insured only applies to the extent permitted by law; and 2. 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 37 04 13 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 55056156 1 20-21 GL AU UMB WC IME/LAR I Nina Lautenschlager 1 4/13/2020 12:59:23 PM (PDT) I Page 4 of 11 Page 1 of 1 POLICY NUMBER: NPC -1003310-00 COMMERCIAL GENERAL LIABILITY CG 20 10 04 13 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - OWNERS, LESSEES 0 CONTRACTORS - SCHEDULED PERSON OR ORGANIZATION I This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Name Of Additional Insured Person(s) Or Organization(s) Locations Of Covered Operations Blanket as required by written contract. Blanket as required by written contract. 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) designated above. However: 1. The insurance afforded to such additional insured only applies to the extent permitted by law; and 2. 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 10 04 13 B. With respect to the insurance afforded to these additional insureds, the following additional exclusions apply: This insurance does not apply to "bodily injury" or "property damage" occurring after: 1. All work, including materials, parts or equipment 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 intended use by any person or organization other than another contractor or subcontractor engaged in performing operations for a principal as a part of the same project. ©Insurance Services Office, Inc., 2012 55056156 1 20-21 GL AU UMB WC IME/LHR I Nina Lautenschlager 1 4/13/2020 12:59:23 PM (PDT) I Page 5 of 11 Page 1 of 2 C. 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. Page 2 of 2 ©Insurance Services Office, Inc., 2012 CG 20 10 04 13 55056156 1 20-21 GL AU UMB WC IME/LHR I Nina Lautenschlager 1 4/13/2020 12:59:23 PM (PDT) I Page 6 of 11 POLICY NUMBER: NPC -1003310-00 COMMERCIAL GENERAL LIABILITY CG 25 03 05 09 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. DESIGNATED CONSTRUCTION PROJECT(S) GENERAL AGGREGATE LIMIT This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART 67NN 11144 Designated Construction Project(s): Policy aggregate limit applies per work site. Information required to complete this Schedule, if not shown above, will be shown in the Declarations. A. For all sums which the insured becomes legally 3. Any payments made under Coverage A for obligated to pay as damages caused by "occur- damages or under Coverage C for medical rences" under Section I — Coverage A, and for all expenses shall reduce the Designated Con - medical expenses caused by accidents under struction Project General Aggregate Limit for Section 1 — Coverage C, which can be attributed that designated construction project. Such only to ongoing operations at a single designated payments shall not reduce the General Ag - construction project shown in the Schedule gregate Limit shown in the Declarations nor above: shall they reduce any other Designated Con - 1. A separate Designated Construction Project struction Project General Aggregate Limit for General Aggregate Limit applies to each des- any other designated construction project ignated construction project, and that limit is shown in the Schedule above. equal to the amount of the General Aggregate 4. The limits shown in the Declarations for Each Limit shown in the Declarations. Occurrence, Damage To Premises Rented To 2. The Designated Construction Project General You and Medical Expense continue to apply. Aggregate Limit is the most we will pay for the However, instead of being subject to the sum of all damages under Coverage A, ex- General Aggregate Limit shown in the Decla- cept damages because of "bodily injury" or rations, such limits will be subject to the appli- "property damage" included in the "products- cable Designated Construction Project Gen - completed operations hazard", and for medi- eral Aggregate Limit. cal expenses under Coverage C regardless of the number of: a. Insureds; b. Claims made or "suits" brought; or c. Persons or organizations making claims or bringing "suits". CG 25 03 05 09 © Insurance Services Office, Inc., 2008 55056156 1 20-21 GL AU UMB WC IME/LHR ( Nina Lautenschlager 1 4/13/2020 12:59:23 PM (PDT) I Page 7 of 11 Pagel of 2 O B. For all sums which the insured becomes legally C. obligated to pay as damages caused by "occur- rences" under Section I — Coverage A, and for all medical expenses caused by accidents under Section I — Coverage C, which cannot be at- tributed only to ongoing operations at a single designated construction project shown in the Schedule above: 1. Any payments made under Coverage A for damages or under Coverage C for medical D. expenses shall reduce the amount available under the General Aggregate Limit or the Products -completed Operations Aggregate Limit, whichever is applicable; and 2. Such payments shall not reduce any Desig- nated Construction Project General Aggre- gate Limit. Page 2 of 2 When coverage for liability arising out of the "products -completed operations hazard" is pro- vided, any payments for damages because of "bodily injury" or "property damage" included in the "products -completed operations hazard" will reduce the Products -completed Operations Ag- gregate Limit, and not reduce the General Ag- gregate Limit nor the Designated Construction Project General Aggregate Limit. If the applicable designated construction project has been abandoned, delayed, or abandoned and then restarted, or if the authorized contract- ing parties deviate from plans, blueprints, de- signs, specifications or timetables, the project will still be deemed to be the same construction pro- ject. E. The provisions of Section 111 — Limits Of Insur- ance not otherwise modified by this endorsement shall continue to apply as stipulated. © Insurance Services Office, Inc., 2008 55056156 1 20-21 GL AU UMB WC IME/LHR I Nina Lautenschlager 1 4/13/2020 12:59:23 PM (PDT) I Page 8 of 11 CG 25 03 05 09 ❑ Policy Number: NPC -1003310-00 COMMERCIAL GENERAL LIABILITY CG 20 01 0413 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE PART The following is added to the Other Insurance Condition and supersedes any provision to the contrary: Primary And Noncontributory Insurance This insurance is primary to and will not seek contribution from any other insurance available to an additional insured under your policy provided that: (1) The additional insured is a Named Insured under such other insurance; and (2) You have agreed in writing in a contract or agreement that this insurance would be primary and would not seek contribution from any other insurance available to the additional insured. CG 20 01 0413 © Insurance Services Office, Inc., 2012 Page 1 of 1 55056156 1 20-21 GL AU UME WC IME/LHR ( Nina Lautenschlager 1 4/13/2020 12:59:23 PM (PDT) I Page 9 of 11 Policy Number: NPC -1003310-00 BLANKET WAIVER OF SUBROGATION The following is added to Section IV -Commercial General Liability Conditions: Waiver of Subrogation We waive any right of recovery we may have against any person or organization because of payments we make for injury or damage arising out of premises owned or occupied or rented or loaned to you; ongoing operations performed by you or on your behalf, done under a contract with that person or organization; "your work"; or "your products". We waive this right where you have agreed to do so as part of a written contract, executed by you prior to loss. Form XIL 436 1208 © 2008, XL America, Inc. Page 7 of 8 Includes copyrighted material of Insurance Services Office, Inc., with its permission. 55056156 1 20-21 GL AU UMB WC IME/LHR I Nina Lautenschlager 1 4/13/2020 12:59:23 PM (PDT) I Page 10 of 11 5 WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 04 03 06 WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT - CALIFORNIA We have the right to recover our payments from anyone liable for an injury covered by this policy. We will not enforce our right against the person or organization named in the Schedule. (This agreement applies only to the extent that you perform work under a written contract that requires you to obtain this agreement from us.) You must maintain payroll records accurately segregating the remuneration of your employees while engaged in the work described in the Schedule. The additional premium for this endorsement shall be 2% of the California workers' compensation premium otherwise due on such remuneration. SCHEDULE PERSON OR ORGANIZATION JOB DESCRIPTION ANY PERSON OR ORGANIZATION FOR WHOM THE BLANKET WAIVER OF SUBROGATION NAMED INSURED HAS AGREED BY WRITTEN CONTRACT TO FURNISH THIS WAIVER This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated. (The information below is required only when this endorsement is issued subsequent to preparation of the policy.) Endorsement Effective: 8/1/2019 Policy No. 7600019322191 Insured: GCI Construction, Inc. Insurance Company: Everest National Insurance Company Countersigned By: Endorsement No. 001 Premium $ INCL. \-W�AtA� - 1998 by the Workers' Compensation Insurance Rating Bureau of California. All rights reserved. From the WCIRB's California Workers' Compensation Insurance Forms Manual - 1999. 55056156 1 20-21 GL AU UMB WC IME/LHR I Nina Lautenschlager 1 4/13/2020 12:59:23 PM (PDT) I Page 11 of 11