Insurance - Michale Balliet Consulting, LLC - 2021-10-27ACC C E RT I F C DATE (MM/DD/YYYY)
ATE OF LIABILITY INSURANCE 10/27/2021
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 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 CONTACT
NAME _ Michael Kosmerl _
Professional Ins. Associates/Ability Insurance Agency Inc. PHONE No Ext : 714/968-9600 FA/ /C' No):
74133 El Paseo, Suite 8 E-MAIL ES_mike(Wabilityins.com
Palm Desert, CA 92260 INSURER(S) AFFORDING COVERAGE r NAIC #
INSURED
Michael Bailiet Consulting, LLC
30181 Outpost Road
San Juan Capistrano, CA 92675
INSURER A :
INSURER B :
INSURER C :
INSURER D :
INSURER E :
CnVFRAGFS CERTIFICATF IUIIMRFR• RwlclnKI KII IRAQ=D-
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;
LTR TYPE OF INSURANCE INSR 1 WVD POLICY NUMBER
POLICY EFF POLICY EXP
MM/DD/YWY MM/DD/YWY LIMITS
GENERAL LIABILITY
EACH OCCURRENCE
1_ 000 000
X COMMERCIAL GENERAL LIABILITY
DAMAGE TO RENTED
PREMISES (Ea occurrence) S
�Q
Xj CLAIMS -MADE OCCUR Y
57SBABF8296Y
MED EXP (Any one person)
10/26/2021 10/26/2022 —
A
PERSONAL & ADV INJURY -
000 000
_--------- __-----.._--_-_-_-__--
GENERAL AGGREGATE $
2000000
GEN'L AGGREGATE LIMIT APPLIES PER:
PRODUCTS - COMP/OP AGG T$
2 000 000
PE O
X
-
POLICY CT LOC
AUTOMOBILE LIABILITY
COMBINED SINGLE LIMIT
(Ea accident) —----.-_-- —---._----------1�000
000
ANY AUTO
BODILY INJURY (Per person) $
B ALL OWNED SCHEDULED y y 57SBABF8296
10/26/2021 10/26/2022 j BODILY INJURY $
_ : AUTOS AUTOS
(Per accident)
NON -OWNED
HIRED AUTOS
_
PROPERTY DAMAGE $
_X _X ! AUTOS
�eraccident
:$
UMBRELLA LIAB OCCUR
EACH OCCURRENCE $
EXCESS LIAB CLAIMS_MADE1
AGGREGATE $
DED RETENTIONS
$
WORKERS COMPENSATION
WC STATU- OTH-'':
AND EMPLOYERS' LIABILITY Y / N
___ TORY LIMITS__ ER
ANY PROPRIETOR/PARTNER/EXECUTIVE
E.L. EACH ACCIDENT $
OFFICER/MEMBER EXCLUDED? N / A
(Mandatory in NH)
E.L. DISEASE - EA EMPLOYEE S
If yes, describe under
-----_._-_--_--
---_----- ___---
DESCRIPTION OF OPERATIONS below
E.L. DISEASE - POLICY LIMIT $
Professional Liability
F N N UDC-4214172-EO-20
07/19/2021 07/19/2022, Liability Limit
$1,000,000
Policy Deductible
$1,000
DESCRIPTION OF OPERATIONS / LOCATIONS J VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required)
Costa Mesa Sanitary District, their elected and appointed officials, agents,
officers, volunteers, and employees listed as Additional
Insured -
pursuant to attached endorsement.
CFRTIFI('ATF Hni nFR rAAI('FI I ATInKI
Costa Mesa Sanitary District
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
290 Paularino Avenue
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
Costa Mesa, CA 92626
ACCORDANCE WITH THE POLICY PROVISIONS.
1
AUTHORIZED REPRESENTATIVE
CC llChG2' k03#✓ef WA Verified by PDFFiller
U 1988-2010 ACORD CORPORATION. All rights reserved.
ACORD 25 (2010/05) The ACORD name and logo are registered marks of ACORD
POLICY NUMBER: 57 SBA BF8296
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
ADDITIONAL INSURED - STATE/POLITICAL SUBDIVISION
CITY OF NEWPORT BEACH
3300 NEWPORT BLVD
NEWPORT BEACH, CA 92663
THE COSTA MESA SANITARY DISTRICT, IT'S ELECTED AND APPOINTED
OFFICIALS, AGENTS, OFFICERS, VOLUNTEERS AND EMPLOYEES
290 PAULARINO AVE
COSTA MESA, CA 92626
THE CITY OF IRVINE AND ITS EMPLOYEES, REPRESENTATIVES
OFFICERS AND AGENTS(CITY AND CITY PERSONNEL)
C/O CERTSONLY-PORTLAND@EBIX.COM
1 CIVIC CENTER PLZ
IRVINE CA 92606
CITY OF IRVINE AND ITS EMPLOYEES,
REPRESENTATIVES, OFFICERS AND AGENTS
PO BOX 257
PORTLAND MI 48875-0257
REF #113-373270
THE CITY OF LOS ALAMITOS, ITS OFFICERS, EMPLOYEES, AGENTS AND
VOLUNTEERS
3191 KATELLA AVE.
LOS ALAMITOS, CA 90720
Form IH 12 00 11 85 T SEQ. NO. 002 Printed in U.S.A. Page 001
Process Date: 0 8 / 11 / 21 Expiration Date: 10 / 2 6 / 2 2
Costa Mesa Sanitary District
290 Paularino Avenue, Costa Mesa, CA 92626
L
In order to comply with District requirements, you are required to provide proof of Workers'
Compensation Insurance. If you have no employees, this form must be signed and returned to:
Costa Mesa Sanitary District
290 Paularino Avenue
Costa Mesa, CA 92626
certify that I do not employ any person in any manner so as to become subject to California
Workers' Compensation Insurance requirements.
I authorize the Costa Mesa Sanitary District to immediately and retroactively revoke any
Agreement/Contract under this declaration if I hire any employee(s) or become subject to the
provision of the laws requiring Workers' Compensation Insurance.
Applicant/Company dame: _
Address: 3 b \S \ boz
CCK\SaNY\,1(
Applicant's Signature:
Title: �`i S L xey
Date Signed: Ck 0)-k
Phone Number: 4� d
Email Address: �.�1'�-
L-LL,
75
Protecting our community's health and the environment by providing solid waste and sewer collection services.
NYWYYa Gov
BUSINESS LIABILITY COVERAGE FORM
This Paragraph f. applies separately to
you and any additional insured.
3. Financial Responsibility Laws
a. When this policy is certified as proof of
financial responsibility for the future under
the provisions of any motor vehicle
financial responsibility law, the insurance
provided by the policy for "bodily injury"
liability and "property damage" liability will
comply with the provisions of the law to
the extent of the coverage and limits of
insurance required by that law.
b. With respect to "mobile equipment" to
which this insurance applies, we will
provide any liability, uninsured motorists,
underinsured motorists, no-fault or other
coverage required by any motor vehicle
law. We will provide the required limits for
those coverages.
4. Legal Action Against Us
No person or organization has a right under
this Coverage Form:
a. To join us as a party or otherwise bring us
into a "suit" asking for damages from an
insured; or
b. To sue us on this Coverage Form unless
all of its terms have been fully complied
with.
A person or organization may sue us to recover
on an agreed settlement or on a final judgment
against an insured; but we will not be liable for
damages that are not payable under the terms of
this insurance or that are in excess of the
applicable limit of insurance. An agreed
settlement means a settlement and release of
liability signed by us, the insured and the
claimant or the claimant's legal representative.
5. Separation Of Insureds
Except with respect to the Limits of Insurance,
and any rights or duties specifically assigned
in this policy to the first Named Insured, this
insurance applies:
a. As if each Named Insured were the only
Named Insured; and
b. Separately to each insured against whom
a claim is made or "suit" is brought.
6. Representations
a. When You Accept This Policy
By accepting this policy, you agree:
(1) The statements in the Declarations
are accurate and complete;
(2) Those statements are based upon
representations you made to us; and
(3) We have issued this policy in reliance
upon your representations.
b. Unintentional Failure To Disclose
Hazards
If unintentionally you should fail to disclose
all hazards relating to the conduct of your
business at the inception date of this
Coverage Part, we shall not deny any
coverage under this Coverage Part
because of such failure.
7. Other Insurance
If other valid and collectible insurance is
available for a loss we cover under this
Coverage Part, our obligations are limited as
follows:
a. Primary Insurance
This insurance is primary except when b.
below applies. If other insurance is also
primary, we will share with all that other
insurance by the method described in c.
below.
b. Excess Insurance
This insurance is excess over any of the
other insurance, whether primary, excess,
contingent or on any other basis:
(1) Your Work
That is Fire, Extended Coverage,
Builder's Risk, Installation Risk or
similar coverage for "your work";
(2) Premises Rented To You
That is fire, lightning or explosion
insurance for premises rented to you
or temporarily occupied by you with
permission of the owner;
(3) Tenant Liability
That is insurance purchased by you to
cover your liability as a tenant for
"property damage" to premises rented
to you or temporarily occupied by you
with permission of the owner;
(4) Aircraft, Auto Or Watercraft
If the loss arises out of the maintenance
or use of aircraft, "autos" or watercraft to
the extent not subject to Exclusion g. of
Section A. — Coverages.
(5) Property Damage To Borrowed
Equipment Or Use Of Elevators
If the loss arises out of "property
damage" to borrowed equipment or
the use of elevators to the extent not
subject to Exclusion k. of Section A. —
Coverages.
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