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Insurance - Robotic Sewer Solutions - 2020-11-19AcoR" CERTIFICATE OF LIABILITY INSURANCE llik.� DATE (MM/DD/YYYY) 1 Costa Mesa Sanitary District 11/19/2020 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). PRODUCERCONTACT Bolton & Company NAME: 3475 E. Foothill Blvd., Suite 100 Pasadena, CA 91107 A/cCNo Ext): (626) 799-7000 jvc, No): ___(626) 583-2117 E-MAIL ADDRESS: INSURER(S) 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 National Insurance Company 25496 INsuRERC: State Compensation Insurance Fund INSURER D: La Crescenta CA 91214 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: 58697444 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. INSIRADDL;SUBR POLICY EFF POLICY EXP T - LTR i TYPE OF INSURANCE INSD WVD POLICY NUMBER MM/DD/YYYY MM/DD/YYYY LIMITS A ✓ COMMERCIAL GENERAL LIABILITY ✓ 0005062710 11/22/2020; 11/22/2021 EACH OCCURRENCE $1,000,000 CLAIMS -MADE ✓ OCCUR DAMAGE TO RENTED PREMISES (Ea occurrence) $ 50,000 ✓ Per Proiect Aggregate MED EXP (Any one person) $1,000 ✓ J Capped at $5,000,000 PERSONAL & ADV INJURY $1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE rt $ 2,000,000 - — - -- - POLICY ✓ J E � LOC PRODUCTS - COMP/OP AGG $ 2,000,000 -- - OTHER: AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT -- (Ea accident) - ANY AUTO BODILY INJURY (Per person) $ OWNED � SCHEDULED BODILY INJURY (Per accident) $ _ AUTOS ONLY _ AUTOS HIRED NON -OWNED PROPERTY DAMAGE $ AUTOS ONLY AUTOS ONLY ^(Per B uMBRELLALIAB V/ OCCUR 87446H2O7ALI 11/22/2020 11/22/2021 EACH OCCURRENCE ! $4,000,000 ✓ EXCESS LIAB y, CLAIMS -MADE: AGGREGATE $4,000,000 DED ✓ RETENTION $0 $ C WORKERS COMPENSATION �/ 1980264 11/22/2020 11/22/2021 ✓ 1 SPER TATUTE 11 ORH AND EMPLOYERS' LIABILITY Y / N -t -- ANYPROPRIETOR/PARTNER/EXECUTIVE E.L. EACH ACCIDENT s$1,000,00 0 OFFICER/MEMBER EXCLUDED? ❑Y N / A —------ (Mandatory in NH) E.L. DISEASE - EA EMPLOYEE; $ If yes, describe under $1 OOO 000 DESCRIPTION OF OPERATIONS below i 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 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION 290 Paularino Avenue DATE THEREOF, NOTICE WILL BE DELIVERED IN Costa Mesa, CA 92626 to ,p�Q QgVM 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 58697444 1 ROBOSEW-01 1 20-21 GL, XS & WC I Alisa Lopez 1 11/19/2020 3:18:20 PM (PST) I Page 1 of 4 POLICY NUMBER: 0005062710 COMMERCIAL GENERAL LIABILITY CG 20 10 07 04 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - OWNERS, LESSEES OR CONTRACTORS - SCHEDULED PERSON OR ORGANIZATION 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 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 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. 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. CG 20 10 07 04 © ISO Properties, Inc., 2004 Page 1 of 1 ❑ 58697444 1 ROBOSEW-01 1 20-21 GL, XS & WC I Alisa Lopez 1 11/19/2020 3:18:20 PM (PST) I Page 2 of 4 POLICY NUMBER: 0005062710 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- tion(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 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 58697444 I ROBOSEW-01 1 20-21 GL, XS & WC I Alisa Lopez 1 11/19/2020 3:18:20 PM (PST) ( Page 3 of 4 0005062710 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 Organization(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 58697444 I ROBOSEW-01 1 20-21 GL, XS & WC I Alisa Lopez 1 11/19/2020 3:18:20 PM (PST) I Page 4 of 4