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Insurance - Robotic Sewer Solutions, Inc. 2023-02-07ACORU' CERTIFICATE OF LIABILITY INSURANCE 164••�-�-� DATE(MM/DD/YYYY) 1 2/7/2023 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 Bolton Insurance Services LLC CONTACT NAME: 3475 E. Foothill Blvd., Suite 100- Pasadena, CA 91107 — - -- — --- o Ext : 6( 26) 799-7000 — ANo): /C, __ _(6>6) 583-2117 PAlp__NA E-MAIL ADDRESS: INSURER(S) AFFORDING COVERAGE NAIC # www.boltonco.com 6004772_ INSURER A: James River Insurance Company — 12203 INSURED Robotic Sewer Solutions, Inc. INSURER B : StarStone National Insurance Company / 25496 — — -- --- — --- 2722 Foothill Blvd. � INSURERC: State Compensation Insurance Fund______ 35076 La Crescenta CA 91214 INSURER D: INSURER E: INSURER F: GUVERAGES CFRTIFICATF NIIMRFR' 7,;1anrszri RF\/IRI(1N AIIIIUIRI=I?• 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 — ---- ------ -- POLICY EFF POLICY EXP LTR TYPE OF INSURANCE IND WVD POLICY NUMBER MM/DD/YYYY MM/DD/YYYY LIMITS A ✓ COMMERCIAL GENERAL LIABILITY ✓ 0005062712 11/22/2022 11/22/2023: EACH OCCURRENCE $_1_,000,000_ DAMAGE TO RENTED + - CLAIMS -MADE ✓ OCCUR PREMISES (Ea occurrences 5.50,000 ✓ Per Protect AggregateMED EXP (Any one person) $ 1,000 ✓ Capped at $5,000,000 PERSONAL & ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE µ $ 2,000,000 POLICY ✓ — ---- -- ---- - PRO- JECT LOC PRODUCTS - COMP/OP AGG $ 2,000,000 OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ _ (Ea accident) ANY AUTO BODILY INJURY (Per person) ;S OWNE- ----- - --- -- - - --- -- AUTOS ONLY AUTOS SCHEDULED BODILY INJURY (Per accident), 5 -_ ;AUTOS ' I __ HIRED NON -OWNED PROPERTY_DAMAGE 5 AUTOS ONLY AUTOS ONLY Per accident ___ 5 B unnBRELLALIAB,/ OCCUR 87446H229AU 11/22/2022 11/22/2023 EACH OCCURRENCE 54,000,000 ✓ EXCESS LIAR - -- CLAIMS -MADE: AGGREGATE $ 4,000,000 DED ✓ RETENTION$0 — - - 5 C WORKERS COMPENSATION 11980264 11/22/2022: 11/22/2023 �/ SPER TATUTE EORH AND EMPLOYERS' LIABILITY Y / N ANYPROPRIETOR/PARTNER/EXECUTIVEE L. EACH ACCIDENT $ $1,000,000 OFFICER/MEMBER EXCLUDED? FYI N / A --- (Mandatory in NH) E.L. DISEASE - EA EMPLOYEE 5 If yes, describe under ----------- - —` 000,000 - --_. DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT 5 $1,000,000 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) GL Additional Insured applies per CG20100704 & CG20370704 attached, only if required by written contract/agreement. GL Primary & Non -Contributory Wording applies per AP5031 US0410 attached. GL Notice of Cancellation Clauses applies per AP2104US1012 attached. Re: License #968766. Additional Insured(s): Costa Mesa Sanitary District, their elected and appointed officials, agents, officers, volunteers, and employees and Crescenta Valley Water District, Los Angeles County, The Certificate of Insurance is subject to policy terms, conditions, limitations and exclusions. CERTIFICATE HOLDER CANCELLATION License #968766 /� SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Costa Mesa Sanitary District (/�'� THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 290 Paularino Avenue ACCORDANCE WITH THE POLICY PROVISIONS. Costa Mesa, CA 92626 AUTHORIZED REPRESENTATIVE Alisa Lopez ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD 729066851 1 ROBOSEW-01 1 22-23 GL, XS & WC I Bolton Certificate Processing 1 2/712023 8:41:42 AM (PST) I Page 1 of 6 POLICY NUMBER: 0005062712 COMMERCIAL GENERAL LIABILITY CG 20 10 07 04 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - OWNERS, LESSEES OR CONTRACTORS - SCHEDULED PERSON OR ORGANIZATION This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Name Of Additional Insured Person(s) Or Organ izations : Locations Of Covered Operations Where required by written contract or written agreement All operations of the Named Insureds Information required to complete this Schedule, if not shown above, will be shown in the Declarations. A. Section 11 — 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) desig- nated above. 'cDZU111mly B. With respect to the insurance afforded to these additional insureds, the following additional exclu- sions apply: This insurance does not apply to "bodily injury" or "property damage" occurring after: 1. All work, including materials, parts or equip- ment 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 in- tended use by any person or organization oth- er than another contractor or subcontractor engaged in performing operations for a princi- pal as a part of the same project. © ISO Properties, Inc., 2004 ,2905851 1 pOBOSEW-01 1 22-23 3L, XS r WC 1 Bolton Certificate Processing 1 2/7j2023 3:41:42 AM (PST, I Page �'f Page 1 of 1 ❑ DATE (MMIDDiYYYY) AC"RV CERTIFICATE OF LIABILITY INSURANCE 02106/2023 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 SCOTT VOSSMEYER NAME;_ n , SCOTT VOSSMEYER, STATE FARM INSURANCE PHONE 818-949-4403 FAX 818-949-4427 AIC, No, ExtL__ 2722 FOOTHILL BLVD E-MAILSCT SCOTTVOSSMEYER COM _ _ADDREU.O3__ --- - __ _� - ---� INSURED LA CRESCENTA, CA 91214 LIC3 OH29947 ROBOTIC SEWER SOLUTIONS, INC. 2722 FOOTHILL BLVD LA CRESCENTA, CA 91214 INSURER(S) AFFORDING COVERAGE MAIC # INSURER A : State Farr^, Mutual Automobile Insurance Company 25178 Costa Mesa Sanitrary Dlsctrict ACCORDANCE WITH THE POLICY PROVISIONS. INSURER B : 0 �' , INSURER C : - _ �; INSURER D INSURER E : INSURER F : L - t ..•.r.. r+r n'rtt-tn A -r= kit tttata IMM. RGVICinkI AiI IMRI`0. wTHIS '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. ADS-'`` Sll ----ifCTG11 F i POLICY ERCP LTR TYPE OF INSURANCE INSD i WVD POLICY NUMBER MMIDDIYYY ! MM/DD ; LIMITS i COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ — i DAMAGE TO RENTED — CLAIMS -MADE OCCURPEE4118E5_tEaocc rrence__ _ MED EXP {Ary one person} $ j PERSONAL & ADV INJURY GENT AGGREGATE LrA a APPLIES PER: GENERAL AGGREGATE E $ PRO- PRODUCTS S CO �P,Oa AGG $ POLICY ':' JECT LOC OTHER. _ $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT I $ 1,000,000 Ea accldeet__ ANY AUTO BODILY ,NJUR`r ,Per person OWNED I SCHEDULED 611 6796 B27 -75D 08/27/2022 08127/2023— _ . A Y BODILY INJURY (Per accident} j $ AUTOS OI,,LY AUTOS H RED NON -OWNED 499 1232 BO 1-75E 08/27/2022 108/27/2023 ' 11 AUTOS O^! 1 =- -, AU*O5 ONLy" mer accident .... __— $- $ -- -- UMBRELLA UABOCCUR EACH OCCURRENCE ($ EXCESS UAB C,_Ai`v15-.L,ADE AGGREGATE $ DED RETENTION $ I $ WORKERS COMPENSATIONPER OTH AND EMPLOYERS' LIABILITY _ __._.STATUTE ;__ : EIR _. $ ANY PROPRIETORiPARTNER/EX .CUTIVE Y 1 N E.L. EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? l ; N r A ( _ (Mandatary in NH) ! E L. DISEASE - EA EMPLOYEE, $ f yes, describe under DESCRIPTION OF OPERATIONS below i E.L. DISEASE - POLICY LIMN $ DESCRIPTION OF OPERATIONS J LOCATIONS 1 VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) The Costa Mesa Sanitary District, its elected and appointed officials, agents, officers, volunterrs and employees are additional insureds. 30 days' notice of cancelation applies a _r . ser, _- M r� A hlr%=l r ATillAr V lVt$t$-ZU"IO A(.;UKU I UKYVKAi ItJIY. An rights reserves. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD 1)01488 132849,14 04_13-2022 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Costa Mesa Sanitrary Dlsctrict ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE ' t 290 Paularino Avenue Costa Mesa, CA 92626 V lVt$t$-ZU"IO A(.;UKU I UKYVKAi ItJIY. An rights reserves. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD 1)01488 132849,14 04_13-2022 POLICY NUMBER: 0005062712 COMMERCIAL GENERAL LIABILITY CG 20 37 07 04 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Name Of Additional Insured Person(s) Or Organ izations : Location And Description Of Completed Opera - tions Where required by written contract or written All operations of the Named Insureds agreement Information required to complete this Schedule, if not shown above, will be shown in the Declarations. Section II — Who Is An Insured is amended to include as an additional insured the person(s) or organiza- tion(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 desig- nated and described in the schedule of this endorse- ment performed for that additional insured and included in the "products -completed operations hazard". CG 20 37 07 04 © ISO Properties, Inc., 2004 Page 1 of 1 72906851 1 ROBOSEW-01 1 22-23 GL, XS & WC I Bolton Certificate Processing 1 2/7/2023 8:41:42 AN (PST) I Page 3 of 6 CZiZ�h'��I:i►XiFa THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. PRIMARY AND NON CONTRIBUTORY ENDORSEMENT This endorsement modifies insurance provided under the following: ALL COVERAGE PARTS Name Of Additional Insured Person(s) Or Oraanization(s): Where Required By Written Contract or Agreement If no entry appears above, this endorsement applies to all Additional Insureds covered under this policy. Any coverage provided to an Additional Insured under this policy shall be excess over any other valid and collectible insurance available to such Additional Insured whether primary, excess, contingent or on any other basis unless a written contract or written agreement specifically requires that this insurance apply on a primary and noncontributory basis ALL OTHER TERMS AND CONDITIONS OF THE POLICY REMAIN UNCHANGED. AP5031 US 04-10 Page 1 of 1 -729C',3351 1 POBOSEW-01 , 22_23 OL, YS E TC I Bolton certificate Processing 1 2,7 2,1323 3:41:42 ANI iPST I Page 4 of 0005062712 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. COMMON POLICY CONDITIONS All Coverage Parts in this policy are subject to the following Conditions. 1. CANCELLATION AND NON -RENEWAL A. The first Named Insured shown in the Declarations may cancel this policy by mailing or delivering to us advance written notice of cancellation. B. We may cancel this policy by mailing or delivering to the first Named Insured written notice of cancellation at least: (1) 10 days before the effective date of cancellation if we cancel for nonpayment of premium; or (2) 30 days before the effective date of cancellation if we cancel for any other reason. C. We will mail or deliver our notice to the first Named Insured's last mailing address known to us. D. Notice of cancellation will state the effective date of cancellation. The policy will end on that date. E. If this policy is cancelled, we will send the first Named Insured any premium refund due. If we cancel, the refund will be pro rata unless cancellation is due to non payment of premium, in which case the refund may be less than pro rata. If the first Named Insured cancels, the refund may be less than pro rata. The cancellation will be effective even if we have not made or offered a refund. F. If notice is mailed, proof of mailing will be sufficient proof of notice. If we elect not to renew this policy, we shall mail written notice to the First Named Insured at the address shown in the Declarations. Such written notice of non -renewal shall be mailed at least 30 days prior to the end of the policy term. 2. CHANGES This policy contains all the agreements between you and us concerning the insurance afforded. The first Named Insured shown in the Declarations is authorized to make changes in the terms of this policy with our consent. This policy's terms can be amended or waived only by endorsement issued by us and made a part of this policy. 3. TRANSFER OF RIGHTS OF RECOVERY AGAINST OTHERS TO US If the insured has rights to recover all or part of any payment we have made under this policy, 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 us enforce them. 4. REPRESENTATIONS By accepting this policy, you agree: A. The statements in the Declarations are accurate and complete; B. Those statements are based upon representations you made to us; and C. We have issued this policy in reliance upon your representations. 5. SERVICE OF SUIT It is agreed that in the event of the failure of this Company to pay any amount claimed to be due hereunder, this Company will submit to the jurisdiction of any court of competent jurisdiction within the United States of America and will comply with all requirements necessary to give such Court jurisdiction and all matters arising hereunder shall be determined in accordance with the law and practice of such Court. It is further agreed that service of process in such suit may be made upon the Company's President, or his nominee, at the address shown on the Declarations page of this policy, and that in any suit instituted against any one of them upon this policy, this Company will abide by the final decision of AP2104US 10-12 Page 1 of 2 72905851 1 ROBOSEW-01 1 22-23 GL, XS & WC 1 Bolton Certificate Processing 1 211'7/2023 8:41:42 Al {PST) I Page 5 of 6 such Court or of any Appellate Court in the event of an appeal. The above-named is authorized and directed to accept service of process on behalf of this Company in any such suit and/or upon the request of the insured to give a written undertaking to the insured that it or they will enter a general appearance upon this Company's behalf in the event such a suit shall be instituted. Further, pursuant to any statute of any state, territory or district of the United States of America, which makes provision therefore, this Company hereby designates the Superintendent, Commissioner or Director of Insurance or other officer specified for that purpose in the statute, or his successor or successors in office, as their true and lawful attorney upon whom may be served any lawful process in any action, suit or proceeding instituted by or on behalf of the insured or any beneficiary hereunder arising out of this contract of insurance, and hereby designates the above-named as the person to whom the said officer is authorized to mail such process or a true copy thereof. 6. TERMS, CONDITIONS AND PREMIUM On each renewal, continuation, anniversary of the effective date of the policy or on an annual basis, the Company will determine the rate and premium and/or amend the terms and conditions in accordance with the rates and rules then in effect. 7. TRANSFER OF YOUR RIGHTS AND DUTIES UNDER THIS POLICY 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. In Witness Whereof, this Company has executed and attested these presents; but this policy shall not be valid unless signed by duly authorized representatives of this Company. VICE PRESIDENT AW 19 AP2104US 10-12 Page 2 of 2 PRESIDENT 72905951 I ?OBOSER-01 1 22-23 GL, XS & WC I Bolton Certificate Processing 1 217/2023 8:41:42 AM (PST, I Page 6 of 6