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Insurance - C & R Drains Inc - 2022-09-09ACORC?� C" CERTIFICATE OF LIABILITY INSURANCE DATE (MMtDD/YYYY) DOCUMENT WITH RESPECT TO WHICH THIS 9(MM/DD2 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: Melissa IgneIIS Burnham WGB Insurance Solutions PHONE FAX CA Insurance License OF69771 (AJC. No. Ext): 714-450-1669 AJC No : 714-573-1770 15901 Red Hill Avenue ADDRESS:__rTnelis w bib.com Tustin CA 92780 INSURERS) AFFORDING COVERA NAIC # PRO - POLICY X ECT LOC INSURER A: Middlesex Insurance Company w 23434 INSURED C&RDR-1 INSURER B : Crum & Forster Specialty Ins C C & R Drains, Inc -- ---_- ___-_--__—_--_ 1525 W. Macarthur Blvd.#11 INSURER C Costa Mesa CA 92626 INSURER D : AUTOS AUTOS _- INSURER E : X X NON -OWNED INSURER F: COVERAGES CERTIFICATE NUMBER: 638004044 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. 290 Paularino Costa Mesa CA 92626 POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER MM/DD/YYYY MMJDDJYYYY ' --- - LIMITS A X COMMERCIAL GENERAL LIABILITY Y Y A0179402004 9/10/2022 9/10/2023 - EACH OCCURRENCE 5 1,000,000 X _ DAMAGE TO RENTED CLAIMS -MADE OCCUR _PREMISES JEa occurrence) S500,000 MED EXP (Any one person) $5,000 PERSONAL & ADV INJURY S 1.000.000 GEN'L AGGREGATE LIMIT APPLIES PER GENERAL AGGREGATE S3,000,000 PRO - POLICY X ECT LOC PRODUCTS -COMP/OP AGG S2,000,000 — - -- - OTHER: S A AUTOMOBILE LIABILITY A0179402001 9/10/2022 9/10/2023 COMBINED SINGLE LIMIT S _(Ea accidentL__ 1,000.000 X ANY AUTO BODILY INJURY (Per person) S ALL OWNED SCHEDULED BODILY INJURY $ AUTOS AUTOS _- (Per accident) X X NON -OWNED PROPERTY DAMAGE S :HIRED AUTOS AUTOS _ (Per accident)_ A )( UMBRELLA LIAB X j OCCUR A0179402006 9/10/2022 9/10/2023 EACH OCCURRENCE $1,000,000 EXCESS LIAB CLAIMS -MADE AGGREGATE S 1,000,000 DED RETENTIONS S A WORKERS COMPENSATION A0179402005 9/10/2022 9/10/2023 X PER AND EMPLOYERS' LIABILITY Y / N STAT UTE ER - : A UTE ANY PROPRIETOR/PARTNER/EXECUTIVE E.L. EACH ACCIDENT S1,000,000 OFFICER/MEMBER EXCLUDED? ❑ N / A ------- (Mandatory in NH) E.L. DISEASE - EA EMPLOYEE; $1.000,000 If yes, describe under ------------ ------------ - DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT S1,000,000 B Pollution Liability CPL114421 9/10/2022 9/10/2023 Each Condition 1,000,000 General Aggregate 2,000,000 DESCRIPTION OF OPERATIONS / LOCATIONS i VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) Certificate holder(s) is/are named as additional insured per the attached endorsements as required by written contract subject to the terms & conditions of the policy: GL Additional Insured - Ongoing Operations Form CG20100413 GL Additional Insured - Completed Operations Form CG20370413 GL Waiver of Subrogation Form CG24040509 GL Per Project Aggregate Form CG25030509 WC - Waiver of Subrogation per Form WC000313 See Attached... CERTIFICATE HOLDER CANCELLATION ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25 (2014/01) The ACORD name and logo are registered marks of ACORD SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN L Costa Mesa Sanitary District ACCORDANCE WITH THE POLICY PROVISIONS. 290 Paularino Costa Mesa CA 92626 AUTHORIZED REPRESENTATIVE ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25 (2014/01) The ACORD name and logo are registered marks of ACORD AGENCY CUSTOMER ID: C&RDR-1 LOC #: AC"R" Page 1 of 1 AGENCY Burnham WGB Insurance Solutions NAMED INSURED C & R Drains, Inc 1525 W. Macarthur Blvd.#11 Costa Mesa CA 92626 POLICY NUMBER CARRIER NAIC CODE EFFECTIVE DATE: ADDITIONAL REMARKS THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, FORM NUMBER: 25 FORM TITLE: CERTIFICATE OF LIABILITY INSURANCE CERTIFICATE HOLDER VESTING: The Costa Mesa Sanitary District, its elected and appointed officials, agents, officers, volunteers and employees Policy shall not terminate, nor shall it be canceled nor the coverage reduced, until thirty (30) days after written notice is given to the District, except 10 Days for Nonpayment - Endorsements to follow ACORD 101 (2008/01) © 2008 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD POLICY NUMBER: A0179402004 COMMERCIAL GENERAL LIABILITY CG 20 37 0413 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. •�� • •' • • ' Hsi • ' %AM 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 Any person or organization you are required to add as All locations and jobs performed that have a written an contract, agreement or permit additional insured under a written contract or agreement in effect prior to any accident, injury, loss or damage 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 0413 A0179402 Middlesex Insurance Company 1 00001 0000000000 21252 0 N 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 eefdefa4-01fc-4585-919f-3cdcfbcd712c Page 1 of 1 09/09/2021 POLICY NUMBER: A0179402004 COMMERCIAL GENERAL LIABILITY CG 20 10 0413 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART U9010M Name Of Additional Insured Person(s) Or Organization(s) Location(s) Of Covered Operations Any person or organization you are required to add as All locations per written contract, agreement or permit an Description: additional insured under a written contract or All jobs performed that have a written contract, agreement agreement or permit in effect prior to any accident, injury, loss or damage 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 A0179402 Middlesex Insurance Company 1 00001 0000000000 21252 0 N 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 048a3e96-a73f-4d8e-9506-64e32f208df3 Page 1 of 2 09/09/2021 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 0413 A0179402 Middlesex Insurance Company 09/09/2021 POLICY NUMBER: A0179402004 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 Designated Construction Project(s): All construction projects away from premise owned by or rented by insured 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 obligated to pay as damages caused by "occurrences" under Section 1- Coverage A, and for all medical expenses caused by accidents under Section 1 - Coverage C, which can be attributed only to ongoing operations at a single designated construction project shown in the Schedule above: 1. A separate Designated Construction Project General Aggregate Limit applies to each designated construction project, and that limit is equal to the amount of the General Aggregate Limit shown in the Declarations. 2. The Designated Construction Project General Aggregate Limit is the most we will pay for the sum of all damages under Coverage A, except damages because of "bodily injury" or "property damage" included in the "products -completed operations hazard", and for medical 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 A0179402 Middlesex Insurance Company 1 00001 0000000000 21252 0 N 3. Any payments made under Coverage A for damages or under Coverage C for medical expenses shall reduce the Designated Construction Project General Aggregate Limit for that designated construction project. Such payments shall not reduce the General Aggregate Limit shown in the Declarations nor shall they reduce any other Designated Construction Project General Aggregate Limit for any other designated construction project shown in the Schedule above. 4. The limits shown in the Declarations for Each Occurrence, Damage To Premises Rented To You and Medical Expense continue to apply. However, instead of being subject to the General Aggregate Limit shown in the Declarations, such limits will be subject to the applicable Designated Construction Project General Aggregate Limit. © Insurance Services Office, Inc., 2008 87de3027-a831-4c64-8b05-0605e43100e6 Pagel of 2 09/09/2021 POLICY NUMBER: A0179402004 COMMERCIAL GENERAL LIABILITY CG 24 04 05 09 WAIVER OF TRANSFER OF RIGHTS OF RECOVERY AGAINST OTHERS TO US This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE PART SCHEDULE Name Of Person Or Organization: Any person or organization from whom you are required to waive your right to recover under a written contract or agreement in effect prior to any loss or damage I Information required to complete this Schedule, if not shown above, will be shown in the Declarations. The following is added to Paragraph 8. Transfer Of Rights Of Recovery Against Others To Us of Section IV - Conditions: We waive any right of recovery we may have against the person or organization shown in the Schedule above because of payments we make for injury or damage arising out of your ongoing operations or "your work" done under a contract with that person or organization and included in the "products -completed operations hazard". This waiver applies only to the person or organization shown in the Schedule above. CG 24 04 05 09 A0179402 Middlesex Insurance Company 1 00001 0000000000 21252 0 N © Insurance Services Office, Inc., 2008 04355dc8-2cb0-4fOc-8a3f-d5219dc75c5c Page 1 of 1 09/09/2021 WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 00 03 13 (Ed. 4-84) WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT 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.) This agreement shall not operate directly or indirectly to benefit anyone not named in the Schedule. Schedule Name: Any person or organization for whom you are required to waive your right to recover under a written contract or agreement in effect prior to any loss or damage Address: 1525 Macarthur Blvd Ste 11 Costa Mesa, CA 92626-1413 Description of Waiver: .. s 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 Policy No. A0179402005 Endorsement No. Insured Premium Insurance Company WC 00 03 13 (Ed. 4-84) ©1983 National Council on Compensation Insurance. Countersigned by A0179402005 Page 1 of 1 Middlesex Insurance Company 09/09/2021 1 00001 0000000000 21252 0 N f80c74a5-27dd-4e39-a3e3-292d964d30ec COMMERCIAL GENERAL LIABILITY CG 20 0104 13 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. . - . • • • • ` • 0 • 41'a 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 CG 20 0104 13 A0179402 Middlesex Insurance Company 1 00001 0000000000 21252 0 N (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. © Insurance Services Office, Inc., 2012 d147d55f--1610-4341-b869-4e847a71bb72 Page 1 of 1 09/09/2021