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Insurance - TankVisions, Inc - 2023-01-12'4CC>RH CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DD/YYYY) CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, 01/12/2023 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 Kim Wykes NAME: Elliott Powell Baden and Baker Inc. PHONE(503) 445-8441 FAX (503) 445-8481 A/C No Ext): A/C, No): An ISU Network Member E-MAIL kw kes e bb.com y @ p EACH OCCURRENCE $ 2,000,000 ADDRESS: 1521 SW Salmon Street INSURER(S) AFFORDING COVERAGE NAIC # Portland OR 97205-1783 INSURERA : Ace Property and Casualty>surance Compan INSURED INSURER B : HiscoX Insurance Co. TankVisions, Inc. INSURER C: 1 Menton INSURER D : INSURER E: Y Newport Coast CA 92657 INSURER F: COVERAGES CERTIFICATE NUMBER: 23-24 GL/NOH/PL/UMB 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. lNSIR 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 ❑X OCCUR EACH OCCURRENCE $ 2,000,000 DAMAGE TO RENTED 1,000,000 PREMISES Ea occurrence S MED EXP (Any one person) S 5,000 PERSONAL&ADV INJURY s 2,000,000 A Y D94711824 01/31/2023 01/31/2024 GEN'LAGGREGATE LIMITAPPLIES PER: POLICY PRO- F-14,000,000 JECT LOC GENERALAGGREGATE S 4,000,000 PRODUCTS COMP/OPAGG S S OTHER: AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT (Ea accident)S 1,000,000 BODILY INJURY (Per person) S ANY AUTO A OWNED SCHEDULED AUTOS ONLY AUTOS D94711824 01/31/2023 01/31/2024 BODILY INJURY (Per accident) S X HIRED X NON -OWNED AUTOS ONLY AUTOS ONLY PROPERTY DAMAGE S (Per accident S X UMBRELLA LIAB X OCCUR EACH OCCURRENCE S 1,000,000 A EXCESS LIAB CLAIMS -MADE D98404065 01/31/2023 01/31/2024 AGGREGATE S DED I I RETENTION S $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS' LIABILITY Y / N STATUTE ER EACH ACCIDENT S ANY PROPRIETOR/PARTNER/EXECUTIVEF—]E.L. OFFICER/MEMBER EXCLUDED? N / A E.L. DISEASE - EA EMPLOYEE S (Mandatory in NH) If yes, describe under E.L. DISEASE - POLICY LIMIT $ DESCRIPTION OF OPERATIONS below B Professional Liability UDC5079188EO22 02/07/2023 02/07/2024 $1,000,000 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) Per attached BOP47675 0316 Re: All operations: Costa Mesa Sanitary District, their elected and appointed officials, agents, officers, volunteers, and employees. CERTIFICATE HOLDER CANCELLATION -(�/ �'� �] SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Costa Mesa Sanitary District ` �/ ACCORDANCE WITH THE POLICY PROVISIONS. 290 Paularino Avenue AUTHORIZED REPRESENTATIVE Costa Mesa CA 92626 to ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD BUSINESSOWNERS LIABILITY EXTENSION THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. This endorsement modifies insurance provided under the following: BUSINESSOWERS COVERAGE FORM TABLE OF CONTENTS This endorsement modifies the coverages provided under the Businessowners Coverage Form. Notwithstanding anything uothe contrary, the provisions cf the BmsineasownereCoverage Form apply, except as provided in this endorsement. The titles of the various paragraphs of this endorsement are inserted solely for convenience or reference and are not to be deemed in any way to limit or affect the provisions to which they A. SUPPLEMENTARY PAYMENTS — BAIL BONDS AND BONDS TO APPEAL JUDGMENTS - NO SUBLIMIT |nSection U - Liability, Paragraph A. Coverages, 1.tCoverage Extension —Supplementary Payments, subparagraphs (1)(b) and (c) are replaced by the following: (b) The cost of bail bonds, but only for bond amounts within the available limit orinsurance, We do not have uofurnish these bonds. (c) The cost ofbonds toappeal judgments mrelease attao ments.butonly for amounts within the available limit of 'insurance. We do not have to furnish these bonds. BOP -47675 (03,116) Includes copyrighted material of Insurance Services Office, Inc.. with its permission, 2016. Page of 11 Page upplementary Payments — Bail Bonds And Bonds To Appeal Judgments — No Sublimit 2 Medical Expenses — Three Years To Report Expenses 2 I—Non-Owned Watercraft Under 55 Feet 2 Non -Owned Aircraft 2 Who Is An Insured — Subsidiaries Or Newly Acquired Or Formed Organizations 3 Who Is An Insured — Employees (Including For CPR arid First Aid) And Volunteer Workers 3 Additional Insured — Lessor Of Leased Equipment 4 I.Additional Insured — Managers Or Lessors Of Premises 4 Additional Insured - Vendors Additional Insured — Other Persons Or Organizations Pursuant To Contract Or Agreeme t 6 Damage To Premises Rented To You — $1,000,000 7 Per Location General Aggregate Limit With Combined Total A gre ate Limit Knowledge/Notice Of Occurrence 9 I Bodily Injury, Including Resulting Mental Anguish 9 q2yff��TerritorV, Limited Worldwide Unintentional Failure To Disclose Hazards 10 10 Other Insurance, Including Primary Provisign 10 Waiver Of Subrogation Required By Contract 12 This endorsement modifies the coverages provided under the Businessowners Coverage Form. Notwithstanding anything uothe contrary, the provisions cf the BmsineasownereCoverage Form apply, except as provided in this endorsement. The titles of the various paragraphs of this endorsement are inserted solely for convenience or reference and are not to be deemed in any way to limit or affect the provisions to which they A. SUPPLEMENTARY PAYMENTS — BAIL BONDS AND BONDS TO APPEAL JUDGMENTS - NO SUBLIMIT |nSection U - Liability, Paragraph A. Coverages, 1.tCoverage Extension —Supplementary Payments, subparagraphs (1)(b) and (c) are replaced by the following: (b) The cost of bail bonds, but only for bond amounts within the available limit orinsurance, We do not have uofurnish these bonds. (c) The cost ofbonds toappeal judgments mrelease attao ments.butonly for amounts within the available limit of 'insurance. We do not have to furnish these bonds. BOP -47675 (03,116) Includes copyrighted material of Insurance Services Office, Inc.. with its permission, 2016. Page of 11 B. MEDICAL EXPENSES — THREE YEARS TO REPORT EXPENSES In Section 11— Liability, Paragraph A. Coverages, 2. Medical Expenses, subparagraph a.(b) is replaced by the following: (b) The expenses are incurred and reported to us within three years of the date of the accident; and C. NON -OWNED WATERCRAFT UNDER 55 FEET In Section 11 - Liability, Paragraph B. Exclusions, subparagraph (2) of Exclusion 1.g. Aircraft, Auto Or Watercraft is replaced by the following: This exclusion does not apply to: (2) A watercraft you do not own that is: (a) Less than 55 feet long; and (b) Not being used to carry persons or property for a charge; D. NON -OWNED AIRCRAFT In Section 11 - Liability, Paragraph B. Exclusions, the following exception is added to Exclusion 1.g. Aircraft, Auto or Watercraft in Section II — Liability: This exclusion does not apply to an aircraft you do not own provided: 1. The pilot in command holds a currently effective certificate, issued by the duly constituted authority of the United States of America or Canada, designating that person as a commercial or airline transport pilot: 2. It is rented with a trained, paid crew; and 3. It does not transport persons or cargo for a charge. E. DAMAGE TO PROPERTY - EXCEPTION FOR EQUIPMENT LOANED OR RENTED TO THE INSURED In Section 11 - Liability, Paragraph B. Exclusions, the following exception is added to Exclusion 1.k Damage To Property: Paragraphs (3) and (4) of this exclusion do not apply to "property damage" to equipment rented or loaned to the insured, provided such equipment is not being used to perform any operations at a construction job site. F. WHO IS AN INSURED - SUBSIDIARIES OR NEWLY ACQUIRED OR FORMED ORGANIZATIONS In Section II - Liability, Paragraph C. Who is an Insured is amended to include the following: If there is no other insurance available, each of the following is also a Named Insured: 1. A subsidiary organization of the first Named Insured shown in the Declarations of which, at the beginning of the policy period and at the time of loss, the first Named Insured controls, either directly or indirectly, more than 50 percent of the interests entitled to vote generally in the election of the governing body of such organization; or BOP -47675 (03/16) Includes copyrighted material of Insurance Services Office, Inc.. with its permission. 2016. Page 2 of 11 o. A subsidiary organization of the first Named Insured shown in the Declarations that the first Named Insured acquires or forms during the policy period, if at the time of loss the first Named Insured controls, either directly or indirectly, more than 50 percent of the interests entitled to vote generally in the election ofthe governing body ofsuch organization. G. WHO IS AN INSURED - EMPLOYEES (INCLUDING CPR AND FIRST AID) AND VOLUNTEER WORKERS In Section 11 - Liability, Paragraph C. Who is an Insured, Paragraph 2.a. is replaced by the following. - 2. Each of the following is also an insured: e. Your ^emp|oyeem^but only for acts within the scope oftheir employment byyou orwhile performing duties related to the conduct of your business. However, no "employee" in on insured for: (1) "Bodily injury" cx"personal and advertising irUury": (a) Toyou, toany o[yourdirectors, managers, membens."executive officers" orpartnens (whether or not an "eniployee') or to any co -"employee" while such injured person is either in the course of his or tier employment or while performing duties related to the conduct ofyour businees� (b) To the brother. chi|d, pareni sister or spouse of such injured person as a consequence ofany injury described inParagraph (e)above�or (u) For which there is any obligation to share damages with or repay someone else who must pay damages because of any injury described in Paragraph (a) or (b) above. With respect to "bodily injury" only, the limitations described in Paragraph 2.a.(1) above do not apply to you or to your directors, managers, members. "executive Officers". partners or supervisors as insureds. The limitations also do not apply to your "employees" aoinsureds, with respect tosuch damages caused bycardiopulmonary resuscitation or first aid services administered by such on ''employee". (2) "Property darnage" to any property owned, Occupied or used by you or by any of your directors, managers, members, "executive officers" or partners (whether or not an ^employee") orby any cfyour ^employees^ This limitation does not apply to "property damage" to premises while rented to you or temporarily occupied by you with the permission ofthe owner. b. Your "volunteer workers", but only while acting within the scope of their activities for you and at your direction. H. ADDITIONAL INSUREDS In Section 11 - Liability, Paragraph C. Who is an Insured, the following is added: 2. Each ofthe following ioalso aninsured: LESSOR OFLEASED EQUIPMENT BOP -47675 (03!16) Includes copyrighted material orInsurance Services Office, mo'with its permission, oo1e. Page sor11 e. Any person or organization from whom you lease equipment, but only with respect to liability for "bodily injury", "property damage" or "personal and advertising injury" caused, in whole or in part, by your maintenance, operation or use of equipment leased to you by such person or organization and only if you are required by a contract or agreement to provide them with such insurance as is afforded by this policy. However, the insurance afforded to such additional insured: (1) Only applies to the extent permitted by law; and (2) Will not be broader than that which you are required by the contract or agreement to provide for such additional insured. With respect to the insurance afforded to these additional insureds, this insurance does not apply to any "occurrence" which takes place after the equipment lease expires. MANAGERS OR LESSORS OF PREMISES f. Any person or organization from whom you lease premises, but only with respect to liability arising out of the ownership, maintenance or use of that part of the premises leased to you and only if you are required by a contract or agreement to provide them with such insurance as is afforded by this policy. However, the insurance afforded to such additional insured: (1) Only applies to the extent permitted by law; and (2) Will not be broader than that which you are required by the contract or agreement to provide for such additional insured. With respect to the insurance afforded to these additional insureds, the following additional exclusions apply: This insurance does not apply to: (1) Any "occurrence" that takes place after you cease to be a tenant in such premises. (2) Structural alterations, new construction or demolition operations performed by or for such additional insureds. I,TI: IZ(7�1:7.'� g. Any person or organization who is a vendor of "your products", but only with respect to "bodily injury" or "property damage" arising out of "your products" which are distributed or sold in the regular course of the vendor's business. However: (1) The insurance afforded to such vendor only applies to the extent permitted by law; and (2) If coverage provided to the vendor is required by a contract or agreement, the insurance afforded to such vendor will not be broader than that which you are required by the contract or agreement to provide for such vendor. BOP -47675 (03/16) Includes copyrighted material of Insurance Services Office. Inc.. with its permission. 2016. Page 4 of 11 With respect to the insurance afforded to these vendors, the following additional exclusions apply: (1) This insurance afforded the vendor does not apply to: (a) "Bodily injury" or "property damage" for which the vendor is obligated to pay damages by reason of the assumption of liability in a contract or agreement. This exclusion does not apply to the liability for damages that the vendor would have in the absence of the contract o,agreement: (b) Any express warranty unauthorized byyouV� (c) Any physical or chemical change in the product made intentionally by the vendor: (d) Repackaging, except when unpacked solely for the purpose of inspection, demonstration, testing or the substitution of parts under instructions from the manufacturer, and then repackaged inthe original container; (e) Any failure to make such inspections, adjustments, tests or servicing as the vendor has agreed to make or normally undertakes to make in the usual course of business, in connection with the distribution orsale ofthe pmduota� (f) Demonstration. installation. servicing or repair operohono, except such operations performed atthe vendor's premises mconnection with the sale ofthe product; (g) Products which. after distribution or sale by you. have been labeled or relabeled or used as a oontsmo,, part or ingredient of any other thing or substance by or for the vendor; or (h) "Bodily injury" or "property damage" arising out of the sole negligence of the vendor for its own acts or omissions or those of its employees or anyone else acting on its behalf. However. this exclusion does not apply to: (i) The exceptions contained |nSubparagraph (d)or(D;or (ii) Such inspections, adjustments, tests or servicing as the vendor has agreed to make or normally undertakes to make in the usual course of business, in connection with the distribution nrsale o[the products. (z) This insurance does not apply to any insured person or organization from whom You have acquired such products, or any ingnadient, part orcontainer entering into, accompanying o, containing such products. With respect to the insurance afforded to these vendors, the following is added to Paragraph D. Liability And Medical Expenses Limits QfInsurance: If coverage provided by the vendor is required by a contract or agreement, the most we will pay on behalf ofthe vendor isthe amount ofinsurance: (1) Required by the contract oragreement or (2) Available under the applicable Limits Of Insurance shown in the Declarations, ooP-47675 (03/e) Includes copyrighted material of Insurance Services Omce, Inc., with its permission. 2016. Page 5 o/ 11 whichever is less. This shall not increase the applicable Limits [fInsurance shown inthe Declarations. OTHER PERSONS {3RORGANIZATIONS PURSUANT TOCONTRACT ORAGREEMENT b Any persons or organizations that you are required by a contract or agreement to provide with such insurance aoisafforded bythis policy. However, such aperson ororganization ioeninsured only: (1) To the extent such contract or agreement requires the additional insured to be afforded status eeoninsured; and (2) For activities that did not occur. in whole or in part, before the execution of the contract or agreement. Noperson ororganization iseninsured under this provision: (1) That iamore specifically identified under any other provision ofParagraph C.Who |aAn Insured (regardless of any limitation applicable thereto). (2) With respect to any assumption of liability in a contract or agreement. This limitation does not apply to the liability for damages the additional insured would have in the absence of the contract oragreement. However, the insurance afforded *oSuch persons ororganizations: (1) Only applies uothe extent permitted bylaw: and (2) Will not be broader than that which you are required by the contract or agreement to provide for such additional insured, The following isadded otthe end ofParagraph C.Who |sAnInsured: No person or organization is an insured with respect to the conduct of any current or past partnership, joint venture or limited liability company that is not shown as a Named Insured in the Declarations. However, noperson ororganization iaaninsured with respect mthe: o. Ownership. maintenance or use of any assets, or b. Conduct of any person or organization whose assets, business or organization; any Named Insured aoquinao, either directly or indirectly, for any: (1) "Bodily injury" nr"property damage" that occurred; or (3) "Personal and advertising injury" arising out of an offense first committed; in whole or in part. before such acquisition is executed. With respect to the insurance afforded to the persons or organizations described in Paragraphs e., f.,. and h. above, the following is added to Paragraph D. Liability And Medical Expenses Limits Of Insurance: BOP -47675 (03/16) Includes copyrighted material ofInsurance Services Office, |no'with its permission, zo1a. Page sor11 The most we will pay on behalf of such person or organization is the amount of insurance� (1) Required bythe contract oragreement; ur (2) Available under the applicable Limits Of Insurance shown in the Declarations; whichever isless. This shall not increase the applicable Limits Of Insurance shown in the Declarations. 1. DAMAGE TO PREMISES RENTED TO YOU — $1,000,000 In Section 11 - Liability, Paragraph D. Liability and Medical Expenses Limits of Insurance, Paragraphs 3.and 4.are deleted and replaced with the following: 3. Subject to the Liability And Medical Expenses Limits Of Insurance, the most we will pay under Business Liability Coverage for damages because of "property damage" to any one premises while rented to you or while temporarily occupied by you with permission of the owner is $1,000,000. 4. Aggregate Limits The most wewill pay for- a. All "bodily injury" and "property damage" that is included in the "prod ucts-com pleted operations hazard" ietwice the Liability and Medical Expenses limit. b. All: (1) "Bodily injury" and "property damage" except damages because of"bodily injury" or"property damage" included inthe ^pmduots-comp|otedoperations hazard^: (2) Plus medical expenses; (o) Plus all "personal and advertising injury" caused byoffenses oommitteu� is twice the Liability and Medical Expenses Limit. The Limits of Insurance of Section 11 — Liability apply separately to each consecutive annual period and to any remaining period or less than 12 montha, starting with the beginning of /he policy period shown in the Declarations, unless the policy period is extended after issuance for an additional period of less than 12 months. In that oaae, the additional period will be deemed part of the last preceding period for purposes ofdetermining the Limits ofInsurance. J. PER LOCATION GENERAL AGGREGATE LIMIT WITH COMBINED TOTAL AGGREGATE LIMIT In Section 11 - Liability, Paragraph D. Liability and Medical Expenses Limits of Insurance, the following is added: BOP -47675 (03!16) Includes copyrighted material of Insurance Services Office. Inc., with its permission. 2016. Page 7or11 1. Subject to the Combined Total Aggregate Limit shown in the Declarations. for the sum of all damages that the insured becomes legally obligated to pay for all "bodily injury" and "property damage" caused by "occurrences" under Paragraph A.1. Business Liability, and for all medical expenses caused by accidents under Paragraph A.2. Medical Expenses, which can be attributed only to a single "location": a. A separate Location General Aggregate Limit will apply to each "location", and that limit is equal to the Other than Products/Completed Operations Aggregate Limit shown in the Declarations. b. The separate Location General Aggregate Limit is the most we will pay for the sum of all damages for "bodily injury" or "property damage" under Paragraph A.1. Business Liability, except in connection with "bodily injury" or "property damage" included in the "products - completed operations hazard", and for medical expenses under Paragraph A.2. Medical Expenses, regardless of the number of: (1) Insureds; (2) Claims made or "suits" brought; or (3) Persons or organizations making claims or bringing "suits". C. Any payments made under Paragraph A.1. or under Paragraph A.2. Medical Expenses shall reduce the separate Location General Aggregate Limit for that "location". Such payments shall not reduce the Other Than Products/Completed Operations Aggregate Limit shown in the Declarations nor shall they reduce the separate Location General Aggregate Limit for any other "location". d. 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 Other Than Products/Completed Operations Aggregate Limit shown in the Declarations, such limits will be subject to the applicable separate Location General Aggregate Limit. 2. Subject to the Combined Total Aggregate Limit shown in the Declarations. for the sum of all damages that the Insured becomes legally obligated to pay for all "bodily injury" or "property damage" caused by occurrences under Paragraph A.1. Business Liability and for all medical expenses caused by accidents under Paragraph A.2., which cannot be attributed only to operations at a single "location". a. Any payments made under Paragraph A.1. Business Liability for damages or under Paragraph A.2. for medical expenses shall reduce the amount available under the Other Than Products/Completed Operations Aggregate Limit or the Products/Completed Operations Aggregate Limit, whichever is applicable; and b. Such payments shall not reduce the separate Location General Aggregate Limit applicable to a single "location". 3. Subject to the separate Location General Aggregate Limit and all other applicable limits, the Combined Total Aggregate Limit shown in the Declarations is the most we will pay for the combined sum of amounts described above, regardless of the number of "locations". 4. Any payments we make for "bodily injury" or "property damage" included in the "products -completed operations hazard" will reduce the Products -Completed Operations Aggregate Limit regardless of the number of "locations", and not reduce the Other Than Products/Completed Operations Aggregate Limit nor the separate Location General Aggregate Limit applicable to a single "location." 5. As used in this endorsement, "location" means premises involving the same or connecting lots, or premises whose connection is interrupted only by a street, roadway, waterway or right-of-way of a railroad. 6. The provisions of Paragraph D. Liability and Medical Expenses Limits Of Insurance not otherwise modified by this endorsement shall continue to apply as stipulated. BOP -47675 (03/16) Includes copyrighted material of Insurance Services Office, Inc.. with its permission. 2016. Page 8 of 11 K. KNOWLEDGE/NOTICE OFOCCURRENCE In Section 11 - Liability, Paragraph E. Liability and Medical Expenses General Conditions, 2. Duties |nthe Event OfOccurrence, Offense, Claim orSuit isamended toinclude the following: e. Knowledge of an "occurrence" or offense by an agent or "employee" of the insured will not constitute knowledge by the insured, unless an "executive officer" (whether or not an "employee") of any insured o,nn"executive off ioer'a^designee knows about such ^oucurrence^oroffense. Failure oran agent or"ernployee" of the insured, other than an "executive officer" (whether or not an "employee") of any insured or an "executive officer's" designee, to notify us of an "occurrence" or offense that such person knows about will not affect the insurance afforded uoyou. f. If a claim or loss does not reasonably appear to involve this insurance, but it later develops into a claim or loss ,o which this insurance epp|iea, the failure to report it to us will not violate this oondit|on, provided the insured gives us immediate notice as soon as the insured is aware that this insurance may apply tosuch loss orclaim. L. BODILY INJURY, INCLUDING RESULTING MENTAL ANGUISH In Section 11 - Liability, Paragraph F. Liability and Medical Expenses Definitions, paragraph 3. is deleted and replaced with the following: 3. "Bodily injury" means pxysiog� a. Injury: u. Sickness-, or u. Disease-, sustained by person, including resulting death, humiliation, mental anguish. mental injury orshock etany time. All such loss shall be deemed to occur at the time of the physical injury, sickness or disease. M. COVERAGE TERRITORY, LIMITED WORLDWIDE In Section U ' Liability, Paragraph F. Liability and K8adice| Expenses Definitions, paragraph 4. is deleted and replaced bythe following: 4. "Coverage territory" means all parts orthe world. However, "coverage territory" does not include any: e. "Bodily injury" or "property damage" that takes place or any offense committed outside of the United States of America (including its possessions and territories), Canada and Puerto R|mo, unless the insured's responsibility to pay damages is determined by a "suit" on the merits that is brought in the United States of America (including its possessions and territories), Canada or Puerto Rico; or u. Injury ordamage inconnection with anv^eu|rbrought outside the United States ofAmerica (including its possessions and temtorios).Canada and Puerto Rico. BOP -47675 (0316) Includes copyrighted material of Insurance Services Office, Inc_ with its permission, 2016. Page sor11 N. UNINTENTIONAL FAILURE TO DISCLOSE HAZARDS In Section III — Common Policy Conditions, Paragraph C. Concealment, Misrepresentation or Fraud is amended to include the following additional paragraph: Unintentional failure of an "employee" of the insured to disclose a hazard or other material information will not violate this condition, unless an "executive officer" (whether or not an "employee") of any insured knows about such hazard or other material information. O. OTHER INSURANCE, INCLUDING PRIMARY PROVISION In Section III — Common Policy Conditions. Paragraph H. Other Insurance, subparagraphs 2. and 3. are replaced by the following: H. Other Insurance If other valid and collectible insurance is available to the insured for a loss we cover under this insurance, our obligations are limited as follows: 1. Primary Insurance This insurance is primary except when Paragraph 2 below applies. If this insurance is primary, our obligations are not affected unless any of the other insurance is also primary. Then, we will share with all that other insurance by the method described in Paragraph 3 below. 2. Excess Insurance a. This insurance is excess over: (1) Any of the other insurance, whether primary, excess, contingent or on any other basis: (a)That is Fire, Extended Coverage, Builder's Risk, Installation Risk or similar coverage for your work"; (b)That is insurance that applies to "property damage' to premises rented to you or temporarily occupied by you with permission of the owner; or (c) If the loss arises out of aircraft. "autos" or watercraft to the extent not subject to Exclusion g. of Section II.B. Exclusions, 1. Applicable to Business Liability Coverage; or (2) Any other primary insurance available to you covering liability for damages arising out of the premises or operations for which you have been added as an additional insured. b. When this insurance is excess, we will have no duty to defend the insured against any "suit" if any other insurer has a duty to defend the insured against that "suit." If no other insurer defends. we will undertake to do so, but we will be entitled to the insured's rights against all those other insurers. c. When this insurance is excess over other insurance, we will pay only our share of the amount of the loss, if any, that exceeds the sum of: (1) The total amount that all such other insurance would pay for the loss in the absence of this insurance; BOP -47675 (03/16) Includes copyrighted material of Insurance Services Office. Inc., with its permission. 2016. Page 10 of 11 (2) The total of all deductible and self-insured amounts under all that other insurance. d. We will share the remaining loss, if any, with any other insurance that is not described in this Excess Insurance provision and was not brought specifically to apply in excess of the Limits of Insurance shown inthe Declarations orthis Coverage Part. Method of Sharing If all of the other insurance permits contribution by equal shares, we will follow this method also. Under this approach, each insurer contributes equal amounts until it has paid its applicable limit of insurance or none orthe loss remains. whichever comes first. If any of the other insurance does not permit contribution by equal shares, we will contribute by limits. Under this method, each insurer's share isbased onthe ratio ofits applicable limit ofinsurance uzthe total applicable limits orinsurance ofall insurers. P. WAIVER OFSUBROGATION REQUIRED BYCONTRACT In Section 111111 — Common Policy Conditions, Paragraph K. Transfer of Rights of Recovery Against Others To Us. subparagraph 2. is replaced bythe KzUowing- 2. Applicable uzBusineeommnemLiability Coverage - We wx|waivethorighuso[reooverywemmuNo/oem°isehavahodagoinat another person ororganization, for loss to which this insurance epp|iea, provided the insured has waived their rights of recovery against such person or organization in u contract oragreement that is executed before such loss. To the extent that the insured's rights to recover all or part of any payment made under this Coverage Part have not been waived, those rights are transferred to us. The insured must do nothing after loss to impair them. At our request, the insured will bring "suit" or transfer those rights to us and help usenforce them. This paragraph does not apply mMedical Expenses Coverage. All other terms and conditions of the policy remain unchanged. BOP -47675 (0316) Includes copyrighted material cxInsurance Services Office, mo,with its permission, 201e. Page 11ox11 r -N esa anitarDistrictCosta 290 Paularino Avenue, Costa Mesa, CA 92626 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 I certify that in the performance of the activity or work for which this permit is issued, I shall 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 the permit issued under this declaration if I hire any employee(s) or become subject to the provision of the laws requiring Workers' Compensation Insurance. Applicant/Company Name: Address: _ — " Applicant's Signature: Title: Ns. I 1 GG - Date Signed: tZiZ Phone Number: Email Address: t`�-�,��.��St� ��-�ti✓� AL Protecting our community's health and the environment by providing solid waste and sewer collection services. www.crosdca.gov