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Insurance - GCI Construction, Inc. 2022-07-12GCICONS-01 JLOPEZ AcoRo CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) llllkl- 7/12/2022 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 CONTACT Jessica Lopez Commercial The Brokerage PHONE^FAX The Brokerage, an Alera Group Company (A/C, No, Ext): (949) 287-5677 _ (A/C, No): E-MAIL 20261 SW Acacia St, Suite 200 ADDRESS:jlopez@thebrokerageins.com Newport Beach, CA 92660 _ INSURER{S) AFFORDING COVERAGE ..... _ NAIC # __ __ wsuRERA:Valley Forge Insurance Company _ 20508 __ INSURED INSURER B: The Continental Insurance Company ;35289 GCI Construction, Inc. INSURERC: 1031 Calle Recodo, Ste D INSURER D SanClemente, CA 92673 - _-_------_-__-_- ---- -----___— __----___-_--_-- -------------__-_-- INSURER E: INSURER F: CC�VFRAC�FC rFRTIFIrATF KlI111ARGR- DCvlclnnl 1.n 1nADCD- 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 SUER POLICY EFF I POLICY EXP LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER MM/DD/YYW MM/DD/YYYY LIMITS A X i COMMERCIAL GENERAL LIABILITY 1,000,000 EACH OCCURRENCE CLAIMS -MADE X OCCUR X 7018617460 4/1/2022 4/1/2023 DAMAGE TO RENTED 100,000 5,000 MED_ EXP (Any oneperson) $ 1,000,000 _PERSONAL & ADV INJURY S _GEN'L AGGREGATE LIMIT APPLIES PER:GENERAL AGGREGATE 2,000,000 PRO POLICY --X JECT LOC PRODUCTS -COMP/OP AGG 2,000,000 OTHER: B AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT 1,000,000 — Ea accident-- -- - $ X ANY AUTO 7018616972 4/1/2022 4/1/2023 BODILY INJURY_tPerperS _ - - OWNED SCHEDULED AUTOS ONLY AUTOS BODILY INJURY (Per accident)'- - --- HIRED NON -OWNED PROPERTY DAMAGE _ AUTOS ONLY _._ AUTOS ONLY Per accident S S B UMBRELLA LIAB X OCCUR_ EACH OCCURRENCE $ �X 4,000,000 EXCESS LIAB CLAIMS -MADE' 7018616986 4/1/2022 4/1/2023 AGGREGATE— - 4,000,000 DED RETENTIONS $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS' LIABILITYY / N --I STATUTE— LL ER ANY PROPRIETOR/PARTNER/EXECUTIVE — OFFICER/MEMBER EXCLUDED?_E. L. EACH ACCIDENT 5 (Mandatory in NH) E.L. DISEASE -_EA EMPLOYEE! S If yes, describe under --- _-- " DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT ! S DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) RE: Removal and Installation of Godwin Unit from Elden Pump Station. glaip The District, its directors, officials, officers, employees, agents, and volunteers are included as Additional Insureds as respects General Liability per attached endorsement. This Insurance shall apply as Primary and Non -Contributory per attached endorsement. SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Costa Mesa Sanitary District �,� C THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 290 Paularino Avenue ACCORDANCE WITH THE POLICY PROVISIONS. Costa Mesa, CA 92626 AUTHORIZED REPRESENTATIVE ACORD 25 (2016/03) © 1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD AGENCY CUSTOMER ID: GC ICONS -01 LOC #: 1 AC40R" �40� ADDITIONAL REMARKS SCHEDULE AGENCY NAMED INSURED : ommercial The Brokerage GCI Construction, Inc. I :1031 Calle Recodo, Ste D 'OLICY NUMBER ISan Clemente, CA 92673 EE PAGE I - --------- :ARRIER NAIC CODE EE PAGE I :;SEE P 1 EFFECTIVE DATE: SEE PAGE 1 ,DDITIONAL REMARKS JLOPEZ - Page 1 of 1 THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, FORM NUMBER: ACORD 26 FORM TITLE: Certificate of Liability insurance Cancellation: *Should this policy be cancelled before the expiration date, The Brokerage, an Alera Group Company will mail 30 (thirty) days written notice to those Certificate Holders which require such action per contract or agreement.* *Except 10 Days Notice of Cancellation for Non -Payment of Premium. ACORD 101 (2008101) @ 2008 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD CNA CNA PARAMOUNT Blanket Additional Insured -Owners, Lessees or Contractors -with Products -Completed Operations Coverage Endorsement This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART It is understood and agreed as follows: 1. WHO IS AN INSURED is amended to include as an Insured any person or organization whom you are required by written contract to add as an additional insured on this coverage part, but only with respect to liability for bodily injury, property damage or personal and advertising injury caused in whole or in part by your acts or omissions, or the acts or omissions of those acting on your behalf: A. in the performance of your ongoing operations subject to such written contract; or B. in the performance of your work subject to such written contract, but only with respect to bodily injury or property damage included in the products -completed operations hazard, and only if: 1. the written contract requires you to provide the additional insured such coverage; and 2. this coverage part provides such coverage. 11. But if the written contract requires: A. additional insured coverage under the 11-85 edition, 10-93 edition, or 10-01 edition of CG2010, or under the 10- 01 edition of CG2037; or B. additional insured coverage with "arising out of" language; or C. additional insured coverage to the greatest extent permissible by law; then paragraph I. above is deleted in its entirety and replaced by the following: WHO IS AN INSURED is amended to include as an Insured any person or organization whom you are required by written contract to add as an additional insured on this coverage part, but only with respect to liability for bodily injury, property damage or personal and advertising injury arising out of your work that is subject to such written contract. III. Subject always to the terms and conditions of this policy, including the limits of insurance, the Insurer will not provide LO such additional insured with: X) A. coverage broader than required by the written contract; or C> CD E: r, C, B. a higher limit of insurance than required by the written contract. IV. The insurance granted by this endorsement to the additional insured does not apply to bodily injury, property damage, or personal and advertising injury arising out of: A. the rendering of, or the failure to render, any professional architectural, engineering, or surveying services, including: 1. the preparing, approving, or failing to prepare or approve maps, shop drawings, opinions, reports, surveys, field orders, change orders or drawings and specifications; and ... 2. supervisory, inspection, architectural or engineering activities; or B. any premises or work for which the additional insured is specifically listed as an additional insured on another -- endorsement attached to this coverage part. ..—.. V. Under COMMERCIAL GENERAL LIABILITY CONDITIONS, the Condition entitled Other Insurance is amended to ..�.... add the following, which supersedes any provision to the contrary in this Condition or elsewhere in this coverage part: CNA75079XX (10-16) Policy No: 7018617460 Page 1 of 2 Endorsement No: Insured Name: GCI Construction, Inc. Effective Date: 4/1/2022 Copyright CNA All Rights Reserved. Includes copyrighted material of Insurance Services Office, Inc., with its permission. CNA CNA PARAMOUNT Blanket Additional Insured -Owners, Lessees or Contractors -with Products -Completed Operations Coverage Endorsement Primary and Noncontributory Insurance With respect to other insurance available to the additional insured under which the additional insured is a named insured, this insurance is primary to and will not seek contribution from such other insurance, provided that a written contract requires the insurance provided by this policy to be: 1. primary and non-contributing with other insurance available to the additional insured; or 2. primary and to not seek contribution from any other insurance available to the additional insured. But except as specified above, this insurance will be excess of all other insurance available to the additional insured. VI. Solely with respect to the insurance granted by this endorsement, the section entitled COMMERCIAL GENERAL LIABILITY CONDITIONS is amended as follows: The Condition entitled Duties In The Event of Occurrence, Offense, Claim or Suit is amended with the addition of the following: Any additional insured pursuant to this endorsement will as soon as practicable: 1. give the Insurer written notice of any claim, or any occurrence or offense which may result in a claim; 2. send the Insurer copies of all legal papers received, and otherwise cooperate with the Insurer in the investigation, defense, or settlement of the claim; and 3. make available any other insurance, and tender the defense and indemnity of any claim to any other insurer or self -insurer, whose policy or program applies to a loss that the Insurer covers under this coverage part. However, if the written contract requires this insurance to be primary and non-contributory, this paragraph 3. does not apply to insurance on which the additional insured is a named insured. The Insurer has no duty to defend or indemnify an additional insured under this endorsement until the Insurer receives written notice of a claim from the additional insured. VII. Solely with respect to the insurance granted by this endorsement, the section entitled DEFINITIONS is amended to add the following definition: Written contract means a written contract or written agreement that requires you to make a person or organization an additional insured on this coverage part, provided the contract or agreement: A. is currently in effect or becomes effective during the term of this policy; and B. was executed prior to: 1. the bodily injury or property damage; or 2. the offense that caused the personal and advertising injury; for which the additional insured seeks coverage. Any coverage granted by this endorsement shall apply solely to the extent permissible by law. All other terms and conditions of the Policy remain unchanged. This endorsement, which forms a part of and is for attachment to the Policy issued by the designated Insurers, takes effect on the effective date of said Policy at the hour stated in said Policy, unless another effective date is shown below, and expires concurrently with said Policy. CNA75079XX10-16 Policy o: 7018617460 Page 2 of 2 Endorsement No: Effective Date: 4/1/2022 Insured Name: GCI Construction, Inc. Copyright CNA All Rights Reserved. Includes copyrighted material of Insurance Services Office, Inc., with its permission. ACOR" CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDD/YWY) CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, 7/13/2022 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. NAME: Jeremy Seltzer 13681 Newport Ave., Ste 8 #622 Tustin, CA 92780 PHONE FAX Ext): -----714-665-9800 _ _LL At /c, NoL 714-665-9801 E GEN'L AGGREGATE LIMIT APPLIES PER: MAIL ADDRESS: Jeremy@cdisi.com PRO - POLICY ,^ JECT LOC INSURER(S) AFFORDING COVERAGE NAIC # www.cdisi.com License #01-116100 INSURER A: Everest National Insurance Company 10120 INSURED INSURER B_ Westchester Surplus Lines Insurance Co 10172 GCI Construction, Inc. -- _- - 1031 Calle Recodo, Ste. D INSURER c San Clemente CA 92673 INSURER D: HIRED NON -OWNED INSURER E: _- AUTOS ONLY __. AUTOS ONLY .- INSURER F: COVERAGES CERTIFICATE NUMBER: 69223921 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; - -- - ,ADDLS BU R ---------------- POLICYEFF POLICYEXP LTR TYPE OF INSURANCE IN D'WVD POLICY NUMBER MM/DDIYYYY MM/DD/YYYY --- ----. ---------- - --- ------ ------ LIMITS COMMERCIAL GENERAL LIABILITY - -, EACH OCCURRENCE $ CLAIMS -MADE OCCUR DAMAGE TO RENTED PREMISES Ea occurrence S AUTHORIZED REPRESENTATIVE MED EXP (Any one person) PERSONAL & ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE PRO - POLICY ,^ JECT LOC PRODUCTS -COMP/OP AGG $ _ _ OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT accident) ------ — ANY AUTO BODILY INJURY (Per person) S OWNED SCHEDULED AUTOS ONLY _ AUTOS BODILY INJURY (Per accident) S HIRED NON -OWNED PROPERTY DAMAGE S _- AUTOS ONLY __. AUTOS ONLY .- Per accident L- r 1__ - - S UMBRELLA LIAB OCCUR EACH OCCURRENCE S - --- - — -_ _ EXCESS LIAB- CLAIMS -MADE, AGGREGATE $ DED RETENTION S $ A WORKERS COMPENSATION 7600022190211 8/1/2021 8/1/2022 /:SPER AND EMPLOYERS' LIABILITY Y / N TATUTE EORH ____ ___ _____._ ! ANYPROPRIETOR/PARTNER/EXECUTIVE E.L. EACH ACCIDENT $1,000,000 OFFICER/MEMBER EXCLUDED? ❑ N / A (Mandatory in NH) $0 Deductible E.L. DISEASE - EA EMPLOYEE' $ 1,000 000 If yes, describe under _ _ DESCRIPTION OF OPERATIONS belowE.L. DISEASE - POLICY LIMIT $ 1,000,000 B 'Pollution 646866435 005 2/2/2022 '2/2/2023 $2,000,000/$2,000,000 Deductible $5,000 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) RE: Removal and Installation of Godwin Unit from Elden Pump Station Certificate is issued as information only in reference to the coverage limits of the named insured. CERTIFICATE HOLDER CANCELLATION Costa Mesa Sanitary District Y 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. 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 59223921 1 21-22 WC Poll I Nina Lautenschlager 1 7/13,12022 7:25:05 AM (PDT) I Page 1 of 2 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 21/% 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: 8/1/2021 Insured: GCI Construction, Inc. Policy No. 7600022190211 Insurance Company: Everest National Insurance Company Countersigned By: Endorsement No. 001 Premium $ INCL. - 1998 by the Workers' Compensation Insurance Rating Bureau of California. All rights reserved. From the wCIRB's California workers' Compensation Insurance Forms Manual - 1999. 69223921 1 21-22 WC Poll I Nina Lautenschlager 1 7%13/2022 7:26:95 AM (PDT) I Page 2 of 2