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Insurance - Sancon Technologies, Inc. - 2021-10-01A�oR" CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DD/YYYY) 10/01/2021 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 E�,�T{ NAME: Pamela Paulino Poms & Associates Insurance Brokers PHONE Ext : (800) 578-8802 FAXNo: (818) 449-9321 CA License #0814733 O, f 1+ E-MAIL ADDRESS: pp @p aulino omsassoc.com 5700 Canoga Ave. #400 INSURER(S) AFFORDING COVERAGE NAIC # Woodland Hills CA 91367 INSURERA: Admiral Insurance 24856 INSURED Costa Mesa Sanitat�y 01stt-ict INSURER B : West American Insurance Company 44393 Sancon Technologies, Inc. INSURER C : Midwest Employers Casualty Company 23612 5841 Engineer Drive INSURER D : INSURER E : Huntington Beach CA 92649 INSURER F : COVERAGES CERTIFICATE NUMBER: 21-22 GL/AU/UMB/WC 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 CONTRACTOR 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 ADDLSUBR INSD WVD POLICY NUMBER POLICY EFF MM/DD/YYYY POLICY EXP MM/DD/YYYY LIMITS X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE � OCCUR EACH OCCURRENCE $ 1,000,000 DAMAGE TO RENTED PREMISES Ea occurrence $ 100,000 MED EXP (Any one person) $ 10,000 PERSONAL &ADV INJURY $ 1,000,000 A Y FEIECC2281005 10/01/2021 10/01/2022 GEN'LAGGREGATE LIMIT APPLIES PER: POLICY � PRO- ❑ JECT LOC GENERAL AGGREGATE $ 2,000,000 PRODUCTS -COMP/OPAGG $ 2,000,000 $ OTHER: AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea accident $ 1,000,000 X ANY AUTO BODILY INJURY (Per person) $ B OWNED SCHEDULED AUTOS ONLY AUTOS BAW2256177090 10/01/2021 10/01/2022 BODILY INJURY (Per accident) $ X HIRED X NON -OWNED AUTOS ONLY /� AUTOS ONLY PROPERTY DAMAGE Per accident $ $ UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 10,000,000 X AGGREGATE $ 10,000,000 A EXCESS LIAR _ CLAIMS -MADE FEIEXS2281105 10/01/2021 10/01/2022 DED I I RETENTION $ $ C WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y / N ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below N/A Y BNUWC0152392 10/01/2921 10i01/2022 SPER X1 TATUTE ER E.L. EACH ACCIDENT $ 1,000,000 E.L. DISEASE - EA EMPLOYEE $ 1,000,000 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) RE: Job No. T19099 - #324 Sewer Manhole Rehabilitation Costa Mesa Sanitary District, its officers, officials, employees, and agents are Included as Additional Insured. Said Insurance is Primary Non -Contributory. Waiver of Subrogation for the Workers Comp applies in favor of same entities. Endorsements per attached. Cancellation Provision also Enclosed. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Costa Mesa Sanitiary District ACCORDANCE WITH THE POLICY PROVISIONS. 290 Paularino Avenue AUTHORIZED REPRESENTATIVE Costa Mesa CA 92626 ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD -04,* x�r_if Sancon Technologies, Inc. Endorsement Number: 30 Additional Insured — Owners, Lessees or Contractors — Completed Operations This endorsement, effective 10/01/2021 attaches to and forms a part of Policy Number FEI-ECC-22810-05. This endorsement changes the Policy. Please read it carefully. In consideration of an additional premium of $Applied, this endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART CCHFT)T TI .F. Name Of Additional Insured Person(s) Or Or anization s : Location And Description Of Completed Operations Any person(s) or organization(s) whom the Named Insured Those project locations where this agrees, in a written contract, to name as an additional insured. endorsement is required by contract. However, this status exists only for the project specified in that 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 © ISO Properties, Inc., 2016 Sancon Technologies, Inc. Endorsement Number: 30 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. CG 20 37 04 13 © ISO Properties, Inc., 2016 Sancon Technologies, Inc. Endorsement Number: 5 Automatic Additional Insured — Owners, Lessees or Contractors This endorsement, effective 10/01/2021 attaches to and forms a part of Policy Number FEI-ECC-22810-05. This endorsement changes the Policy. Please read it carefully. In consideration of an additional premium of $Applied, this endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART CONTRACTORS POLLUTION LIABILITY COVERAGE PART .% NF.T)T TT .F. Name of Person or Organization: Any person(s) or organization(s) whom the Named Insured agrees, in a written contract, to name as an additional insured. However, this status exists only for the project specified in that contract. The person or organization shown in this Schedule is included as an insured, but only with respect to that person's or organization's vicarious liability arising out of your ongoing operations performed for that insured. ECC-319-0712 Sancon Technologies, Inc. Endorsement Number: 16 Automatic Primary and Non -Contributory Insurance Endorsement Designated Work Or Project(s) This endorsement, effective 10/01/2021 attaches to and forms a part of Policy Number FEI-ECC-22810-05. This endorsement changes the Policy. Please read it carefully. This endorsement modifies insurance provided under the Coverage Part(s) indicated below: COMMERCIAL GENERAL LIABILITY COVERAGE CONTRACTORS POLLUTION LIABILITY COVERAGE SCHEDULE Name of Person or Organization: Any person(s) or organization(s) whom the Named Insured agrees, in a written contract, to provide Primary and/or Non-contributory status of this insurance. However, this status exists only for the project specified in that contract. In consideration of an additional premium of $Applied and notwithstanding anything contained in this policy to the contrary, it is hereby agreed that this policy shall be considered primary to any similar insurance held by third parties in respect to work performed by you under any written contractual agreement with such third party. It is further agreed that any other insurance which the person(s) or organization(s) named in the schedule may have is excess and non- contributory to this insurance. ECC-548-0317 POLICY NUMBER: BNUWC0152392 WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 04 03 06 (Ed. 04-84) WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT CALIFORNIA (Blanket) 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 0.020000 % of the California workers' compensation premium otherwise due on such remuneration. Schedule State Description CA Any party with whom the insured agrees to waive subrogation in a written contract. 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 Date: 10/01/2021 Policy Number: BNUWC0152392 Endorsement No.: Insured Name: Sancon Technologies, Inc. Insurance Company: Midwest Employers Casualty Company Countersigned By—�� Sancon Technologies, Inc. Endorsement Number: 2 ,scut Common Policy Conditions Endorsement This endorsement, effective 10/1/2021 attaches to and forms a part of Policy Number FEI-ECC-22810-05. This endorsement changes the Policy. Please read it carefully. In consideration of the premium charged, and notwithstanding anything contained in this policy to the contrary, it is hereby agreed that all coverage parts included in this policy are subject to the following conditions: A. CANCELLATION The named insured may cancel this policy by mailing to the Company written notice stating when thereafter such cancellation shall become effective. The Company may cancel this policy by mailing to the named insured, at the mailing address specified the Declarations, written notice stating when not less than thirty (30) days thereafter such cancellation shall become effective, except in the event of the named insured's nonpayment of premium, not less than ten (10) days advance notice of cancellation shall be given. The mailing of notice as aforesaid, shall be sufficient proof of either party's intent to cancel. The effective date of cancellation specified in such notice shall terminate this policy period. Delivery of such notice shall be equivalent to mailing. If the named insured cancels, the earned premium shall be computed in accordance with the customary short rate table. If the Company cancels, the earned premium shall be computed pro rata. The Company will tender any return premium subject to retaining a minimum earned premium equal to 25% of the amount specified in the Declarations. Premium adjustment may be made either at the time cancellation is effective or as soon as practicable thereafter, but tender of the unearned premium or return of this policy, shall not be conditions precedent to cancellation hereunder. B. CHANGES No provision of this policy may be amended, waived or otherwise changed, except by endorsement hereto. ECC-315-0712 Sancon Technologies, Inc. Endorsement Number: 2 AM) W4L *CMULAAMAY' C. EXAMINATION OF YOUR BOOKS AND RECORDS We may examine and audit your books and records as they relate to this policy at any time during the policy period and up to three (3) years afterward. D. INSPECTIONS AND SURVEYS We have the right, but are not obliged to: 1. Make inspections and surveys at any time; and 2. Give you reports on the conditions we find; and 3. Recommend changes. Any inspections, surveys, reports or recommendations relate only to insurability and the premiums to be charged. We do not make safety inspections. We do not undertake to perform the duty of any person or organization to provide for the health or safety of workers or the public. We do not warrant that conditions: 1. Are safe or healthful; or 2. Comply with laws, regulations, codes or standards. This condition applies not only to us, but also to any rating, advisory, rate service, engineering firm or similar organization which makes insurance inspections, surveys, reports or recommendations. E. NAMED INSURED AS AGENT The named insured specified in the Declarations shall be deemed agent of each insured with respect to all matters involving this policy, however, the Company shall have the right to seek indemnification from any insured or any other person who may be legally liable for the debts of the named insured. ECC-315-0712 Sancon Technologies, Inc. Endorsement Number: 2 F. PREMIUMS The first Named Insured shown in the Declarations: 1. Is responsible for the payment of all premiums; and 2. Will be the payee for any return premiums we pay; and 3. Is responsible for the payment of all deductibles and self -insured retention amounts under this policy. G. ADDITIONAL PREMIUMS If, during this policy period, an increase in the risk or hazards covered hereunder occurs, the Company shall have the right to charge the appropriate additional premium. H. TRANSFER OF YOUR RIGHTS AND DUTIES UNDER THIS Your rights and duties under this policy may not be transferred without our written consent except in the case of death of an individual Named Insured. If you die, your rights and duties will be transferred to your legal representative but only while acting within the scope of duties as your legal representative. Until your legal representative is appointed, anyone having proper temporary custody of your property will have your rights and duties but only with respect to that property. I. BANKRUPTCY Bankruptcy or insolvency of the insured or of the insured's estate will not relieve us of our obligations under this Coverage Part. ECC-315-0712