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Insurance - GCI Construction - 2012-03-02 ------Th OP ID: BS A�°R° CERTIFICATE OF LIABILITY INSURANCE DATE 03/0/DIYYYYI 03102/12 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 855-403-9800 NAMEACT Compass Direct Ins Svc, Inc. 71 q-665-9801 PHONE FAX 13681 Newport Ave. Ste 8#622 INC No E41. (AJC,No). Tustin,CA 92780 EMAIL ADDRESS' PRODUCER GCICO-1 CUSTOMER ID k: INSURER(S)AFFORDING COVERAGE NAIC 11 INSURED GCI Construction Inc INSURER A,Gr at Ame Ass eCo 26344 245 Fischer Ave. Ste B3 INSURER B.We In Company 25011 Costa Mesa, CA 92626 INSURER C.Ev st Na al In Co 10120 INSURER D.AGES Ma eln Compan 22837 INSURER E.As Co of Ame (Zu ch) INSURER F COVERAGES CERTIFICATE NUMBER: 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 ADDLTSUBR POLICY EFF POLICY EXP LTRI TYPE OF INSURANCE INSRI WVDI POLICY NUMBER I IMM/DD/YYYYI I(MM/DD/YYYY) LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 A X COMMERCIAL GENERAL LIABILITY X X GLP2100779 04/01/11 04/01/12 DAMAGETORENTED PREMISES(Ea occurrence) $ 50,000 CLAIMS-MADE X OCCUR MED EXP(Any e person) I$ Excluded X Own es/Cont.Pr PERSONAL&ADV INJURY I $ 1,000,000 X XCU/Deductible $5,000 GENERAL AGGREGATE I$ 2,000,000 GENII AGGREGATE LIMIT APPLIES PER PRODUCTS COMP/OP AGG $ 2,000,000 I POLICY I X I JECT I I LOC Emp. Ben. $ 1,000,000 AUTOMOBILE LIABILITY X X I COMBINED SINGLE LIMIT B © ANY AUTO WPP1020640 04/01/11 04/01/12 (Ea accident) I$ 1,000,000 BODILY INJURY(Per person) I$ ■ ALL OWNED AUTOS BODILY INJURY(Pe accident)I$ ■ SCHEDULED AUTOS NO LIABILITY DEDUCTIBLE PROPERTY DAMAGE $ © HIRED AUTOS (Pe accident) © NON-OWNED AUTOS $ X Comp/Coll Ded $1000 .. I$ X UMBRELLA LIAB IXI OCCUR EACH OCCURRENCE I$ 4,000,000 EXCESS LIAR I—{ A CLAIMS-MADE X X UMB2100779 04/01/11 04/01/12 AGGREGATE $ 4,000,000 DEDUCTIBLE $ RETENTION $ $ WORKERS COMPENSATION WC STATU- 0TH AND EMPLOYERS'LIABILITY TORY LIMITS X ER Y/N C ANY PROPRIETOR/PARTNER/EXECUTIVE 7600001466111 03/17/11 03/17/12 EL EACH ACCIDENT I$ 1,000,000 OFFICER/MEMBER EXCLUDED, N/A X (Mandatory NH) E L DISEASE EA EMPLOYEE $ 1,000,000 If yes,descnbe under DESCRIPTION OF OPERATIONS below EL DISEASE POLICY LIMIT I $ 1,000,000 D IM-Eqp/Lesd.Hrd.R MXI98401780 04/01/11 04/01/12 Sch Limit 641k/10k E ICOC Zurich BR70274487 05/17/11 05/17/12 Limit 198,527 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (Attach ACORD 101,Add, at Remarks Schedule If mo spa equ ed) Certificate holder and its employees, agents and officials are named as additional insured as per attached endorsements with respects to work performed by the insured ,as per contract Project 171 Irvine Force Main Rehabilitation *10 day notice for non-payment of premium* CERTIFICATE HOLDER CANCELLATION Should any of the above described policies be cancelled before the expiration date therof,the issuing insurer will mail 30 days Costa Mesa Sanitary District written notice to the certificate holder named to the left. 628 W. 19th Street AUTHORIZED REPRESENTATIVE Costa Mesa, CA 92627 I ©1988 '109 A•ORD .,• ••• • •N. All rights reserved. ACORD 25(2009/09) The ACORD name and logo are regis • •• marks • • • • • CALIFORNIA ALL-PURPOSE ACKNOWLEDGMENT c-acecealvrcrerccaccocacc•.ccee c•.e cocaeee ,w,ococcovreroe-,ceecererc2caceeccer rvrceerercrce State of California 1 County of C'crsxtc Q— Ji �/ On 3 2,- 12 > before me, S ,r\c�.` c, 4d I�IC>to.vu (��p11Ci Date He e Ins rt Name an Title of the Officer personally appeared 3 etext1I.\ cS2+ p c Name(r)of Signer who proved to me on the basis of satisfactory evidence to be the person(s5 whose name(s3-is/are-subscribed to the within instrument and acknowledged to me that he/she/they executed the same in hislher/their authorized capacity(), and that by his/her/their signature( on the instrument the person(s), or the entity upon behalf of which the person(?) acted, executed the instrument. SANDRAROOKEp I certify under PENALTY OF PERJURY under the laws ,-ri_ Commission• 1886918 ` 4 Notary Public California of the State of California that the foregoing paragraph is lyi Orange + County true and correct. - M Comm.Ex its r24 2014 WITNESS my hand and official seal. ` Signature_/ i 000- ,�.3> Pla Notary Seal Abo Sign t e of Notary Lc OPTIONAL Though the information below is not required by law, it may prove valuable to persons relying on the document and could prevent fraudulent removal and reattachment of this form to another document. Description of Attached Document Title or Type of Document Document Date: Number of Pages: Signer(s) Other Than Named Above: Capacity(ies) Claimed by Signer(s) Signer's Name: Signer's Name: ❑ Individual ❑ Individual ❑ Corporate Officer—Title(s): U Corporate Officer—Title(s): ❑ Partner—❑ Limited ❑ General RIGHTTHUMBPRINi ❑ Partner—❑ Limited ❑ General RIGHT THUMBPRINT ❑ Attorney in Fact OF SIGNER ❑Attorney in Fact OF SIGNER ❑ Trustee Top of thumb he ❑Trustee Top of thumb he ❑ Guardian or Conservator ❑ Guardian or Conservator ❑ Other- ❑ Other Signer Is Representing: Signer Is Representing: ticiww�--e• ex--e^wiciw vi=v^wce:-<x-e^wi-ewe^finicitici x-cxiciit .,w^citw— w•u^w^writiv- 1-4:1-4nx.^ww^ux.c.Yctivciexe 02007 Natio at Notary Aasoaatio •9350 De Soto Ave PO Bo 2402•Chatsworth,CA 91313-2402•www Natio alNotaryorg Item#5907 Heordo Call Toll-Fr 1-800876-6827 Insured: GC! Construction, Inc. CG 20 37 Policy#GLP2100779 (Ed 07 04) Policy Period: 04/01/2011 04/01/2012 THIS ENDORSEMENT CHANGES THE POLICY PLEASE READ IT CAREFULLY ADDITIONAL INSURED - OWNERS, LESSEES OR CONTRACTORS - COMPLETED OPERATIONS This endorsement modifies insurance provided under the following COMMERCIAL GENERAL LIABILITY COVERAGE PART Schedule Name of Additional Insured Person(s) or Organization(s): Location and Description of Completed Operations: Any person nr organization that Per Certificate ( sI of Insurance you and such person or organiza tion have agreed in writing in a contract or agreement that such Your work performed during this policy person or organization be added as period an additional insured on your policy but only for your work performed during this policy period Additional Premium Included 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 personls) or organizationls) 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. Copyright, ISO Properties, Inc. 2004 CG 20 37 (Ed. 07/04) PRO (Page 1 of 11 Great American Assurance Company GCI Construction, Inc CG 2033 Policy # GLP2100779 (Ed 07 04) Effective: 04/01/11 THIS ENDORSEMENT CHANGES THE POLICY PLEASE READ IT CAREFULLY ADDITIONAL INSURED — OWNERS, LESSEES OR CONTRACTORS — AUTOMATIC STATUS WHEN REQUIRED IN CONSTRUCTION AGREEMENT WITH YOU This endorsement modifies insurance provided under the following COMMERCIAL GENERAL LIABILITY COVERAGE PART A. SECTION II - WHO IS AN INSURED is This insurance does not apply to: amended to include as an Additional Insured any person or organization for whom you are 1. 'Bodily injury, 'property damage" or 'per- performing operations when you and such sonal and advertising injury" arising out of person or organization have agreed in writing the rendering of, or the failure to render in a contract or agreement that such person any professional architectural, engineering or organization be added as an Additional In- or surveying services, including sured on your policy. Such person or or- ganization is an Additional Insured only with a. the preparing, approving, or failing to respect to liability for "bodily injury, "prop- prepare or approve, maps, shop erty damage" or "personal and advertising in- drawings, opinions, reports, surveys, jury" caused, in whole or in part, by: field orders, change orders or draw- ings and specifications; or b. supervisory, inspection, architectural 1. your acts or omissions; or or engineering activities. 2. "Bodily injury, or 'property damage' oc- 2. the acts or omissions of those acting on curring after your behalf• a. all work, including materials, parts or equipment furnished in connection in the performance of your ongoing oper- with such work, on the project (other ations for the Additional Insured. than service, maintenance or repairs) to be performed by or on behalf of the Additional Insured(s) at the location A persons or organization's status as an Ad- of the covered operations has been ditional Insured under this endorsement ends completed; or when your operations for that Additional In- b. that portion of "your work" out of sured are completed which the injury or damage arises has been put to its intended use by any person or organization other than an- B. With respect to the insurance afforded to other contractor or subcontractor en- these Additional Insureds, the following addi- gaged in performing operations for a tional exclusions apply. principal as a part of the same project Copyright, ISO Properties, Inc. 2004 CG 20 33 (Ed. 07/04) XS Insured: GC! Construction, Inc. GAC 3649CG Policy#GLP2100779 .(Ed. 11 061 Policy Period: 04/01/2011 04/01/2012 THIS ENDORSEMENT CHANGES THE POLICY PLEASE READ IT CAREFULLY PRIMARY NON-CONTRIBUTORY INSURANCE ENDORSEMENT This endorsement modifies insurance provided under the following COMMERCIAL GENERAL LIABILITY COVERAGE FORM OWNERS AND CONTRACTORS PROTECTIVE LIABILITY COVERAGE FORM This insurance is primary to any other insurance held by third parties with respect to work performed by you under written contractual agreements with such third parties and any other insurance which may be available to such third parties shall be non—contributory GAC 3649CG (Ed. 11/06) XS Insured: GCI Construction, Inc CG 24 04 Policy# GLP2100779 (Ed 05 09) Policy Period: 04/01/2011 04/01/2012 THIS ENDORSEMENT CHANGES THE POLICY PLEASE READ IT CAREFULLY 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 for whom or on whose behalf you are performing operations when you and such person or organization have agreed in writing in a contract or agreement to waive any right of recovery we may have against such person or organization 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. Copyright, ISO Properties, Inc 2008 CG 24 04 (Ed 05/091 PRO (Page 1 of 1) CG 25 03 (Ed. 03 97) THIS ENDORSEMENT CHANGES THE POLICY PLEASE READ IT CAREFULLY DESIGNATED CONSTRUCTION PROJECTIS) GENERAL AGGREGATE LIMIT This endorsement modifies insurance provided under the following. COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Designated Construction Projects: Any construction project where you are performing operations when you have agreed in writing in a contract or agreement that a separate General Aggregate Limit shall apply to such construction project but only if your work on or at the construction project is performed during the period of this policy (If no entry appears above, information required to complete this endorsement will be shown in the Declarations as applicable to this endorsement) A. For all sums which the Insured becomes legally obligated to pay as damages caused by occurrences under COVERAGE A. (SECTION I), and for all medical expenses caused by accidents under COVERAGE C. (SECTION II, 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 Copyright, Insurance Services Office, Inc. 1996 CG 25 03 IEd 03/97) PRO (Page 1 of 21 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, Fire Damage 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 B. For all sums which the Insured becomes legally obligated to pay as damages caused by occurrences under COVERAGE A. (SECTION I), and for all medical expenses caused by accidents under COVERAGE C. (SECTION I), which cannot be attributed only to ongoing operations at a single designated construction project shown in the Schedule above 1. any payments made under Coverage A. for damages or under Coverage C. for medical expenses shall reduce the amount available under the General Aggregate Limit or the Products-Completed Operations Aggregate Limit, whichever is applicable, and 2. such payments shall not reduce any Designated Construction Project General Aggregate Limit. C. When coverage for liability arising out of the products-completed operations hazard' is provided, any payments for damages because of 'bodily injury or 'property damage included in the 'products-completed operations hazard" will reduce the Products-Completed Operations Aggregate Limit, and not reduce the General Aggregate Limit nor the Designated Construction Project General Aggregate Limit. D If the applicable designated construction project has been abandoned, delayed, or abandoned and then restarted, or if the authorized contracting parties deviate from plans, blueprints, designs, specifications or timetables. the project will still be deemed to be the same construction project E. The provisions of LIMITS OF INSURANCE (SECTION III) not otherwise modified by this endorsement shall continue to apply as stipulated. Copyright, Insurance Services Office, Inc. 1996 CG 25 03 (Ed. 03/971 PRO (Page 2 of 21 ABA1299 POLICY NUMBER: wPP1020640 00 COMMERCIAL AUTO CA 20 48 02 99 THIS ENDORSEMENT CHANGES THE POLICY PLEASE READ IT CAREFULLY DESIGNATED INSURED This endorsement modifies insurance provided under the following: BUSINESS AUTO COVERAGE FORM GARAGE COVERAGE FORM MOTOR CARRIER COVERAGE FORM TRUCKERS COVERAGE FORM With respect to coverage provided by this endorsement, the provisions of the Coverage Form apply unless modi- fied by this endorsement. This endorsement identifies person(s) or organization(s) who are 'insureds' under the Who Is An Insured Provi- sion of the Coverage Form. This endorsement does not alter coverage provided in the Coverage Form. This endorsement changes the policy effective on the inception date of the policy unless another date is indi- cated below Endorsement Effective: Countersigned By 11/01/11 Named Insured: GCI CONSTRUCTION INC Autho ' d Representative) CME INC SCHED Name of Person(s) or Organization(s): ANY PERSON OR ORGANIZATION WHOM YOU HAVE AGREED IN A WRITTEN CONTRACT EXECUTED PRIOR TO LOSS TO NAME AS ADDITIONAL INSURED (If no entry appears above, information required to complete this endorsement will be shown in the Declarations as applicable to the endorsement.) Each person or organization shown in the Schedule is an 'insured' for Liability Coverage, but only to the extent that person or organization qualifies as an 'insured' under the Who Is An Insured Provision contained in Section II of the Coverage Form. SUCH INSURANCE AS IS AFFORDED BY THIS POLICY SHALL BE PRIMARY INSURANCE, AND ANY INSURANCE OR SELF-INSURANCE MAINTAINED BY THE ABOVE ADDITIONAL INSURED SHALL BE EXCESS OF THE INSURANCE AFFORDED co THE NAMED INSURED AND SHALL NOT CONTRIBUTE TO IT. WAIVER OF SUBROGATION APPLIES CA 20 48 02 99 Copyright, Insurance Services Office, Inc. 1998 Page 1 of 1 ❑ INSURED 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 2 % of the California workers compensation premium otherwise due on such remuneration. SCHEDULE PERSON OR ORGANIZATION JOB DESCRIPTION ANY PERSON OR ORGANIZATION FOR WHOP BLANKET rWAIVER OF SUBROGATION THE 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 03 17 11 Policy No. 7600001466111 Endorsement No. 001 Insured GCI CONSTRUCTION INC Premium S INCL Insurance Company EVEREST NATIONAL INSURANCE COMPANY Countersigned By 1998 by the Workers'Compensation insurance Rating Bureau of California. All rights reserved. �J\ From the WCIRB's California Workers' Compensation Insurance Forms Manual 1999. RURED CON