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Insurance - GCI Construction - 2011-04-05 "1 OP ID: AA ac--- CERTIFICATE OF LIABILITY INSURANCE DATE DIYYYY) �� 04/04111 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 CONTACT Compass Direct Ins Svc,Inc. 7 PHONE FAX 14-665-9801 13681 Newport Ave. Ste 8#622 IA/C,No,Exq: (A/CC No): . Tustin,CA 92780 E-MAIL ADDRESS: PRODUCER GCICO-1 CUSTOMER ID#: INSURER(S)AFFORDING COVERAGE NAIC# INSURED GC!Construction Inc R E C Ell V F D INSURER A.Great American Assurance Co. 26344 245 Fischer Ave. Ste B3 INSURER B.Wesco Insurance Company 25011 Costa Mesa, CA 92626 APR - 5 2011 INSURER C Everest National Insurance Co. 10120 INSURERD AGCS Marine Insurance Company 22837 COSTA MESA Ut, INSURER E.Ass. Co. of America (Zurich) 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 ILTq TYPE OF INSURANCE ADDL SUER POLICY EFF POLICY EXP INSR WVDI POLICY NUMBER I(MMIDDIYYYY) IMM/DD/YYYYI LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 A X COMMERCIAL GENERAL LIABILITY X GLP2100779 04/01/11 04/01/12 DAMAGE TO RENTED 50,000 PREMISES(Ea occurrence) $ CLAIMS-MADE I X OCCUR MED EXP(Any one person) $ Excluded X Owner's/Cont.Pro PERSONAL&ADV INJURY S 1,000,000 X XCU/Deductible $5,000 GENERAL AGGREGATE _ $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER PRODUCTS COMP/OP AGG $ 2,000,000 POLICY I n I Pc° LOC Emp.Ben. $ 1,000,000 AUTOMOBILE LIABILITY X COMBINED SINGLE LIMIT (Ea ac $ 1,000,000 accident) B X I ANY AUTO WPP1020640 04/01/11 04/01/12 BODILY INJURY(Per pe n) E ALL OWNED AUTOS BODILY INJURY(Pe acadenl) S SCHEDULED AUTOS PROPERTY DAMAGE X HIRED AUTOS (Pe cadent) S X NON-OWNED AUTOS $ X Comp/Coll Ded I $1000 $ UMBRELLA LIAB X OCCUR EACH OCCURRENCE S 4,000,000 EXCESS LIAB CLAIMS-MADE AGGREGATE S 4,000,000 A - UMB2100779 04/01/11 04/01/12 DEDUCTIBLE __ S RETENTION S I S WORKERS COMPENSATION I WC STATU- X OTH- AND EMPLOYERS'LIABILITY TORY LIMITS ER C ANY PROPRIETOR/PARTNER/EXECUTIVE YIN 7600001466111 03/17/11 03/17/12 EL EACH ACCIDENT S 1,000,000 OFFICER/MEMBER EXCLUDED? N/A — (Mandatory NH) EL DISEASE EA EMPLOYEE S 1,000,000 If yes,describe under DESCRIPTION OF OPERATIONS below EL DISEASE POLICY LIMIll S 1,000,000 D IIM-Eqp./Lesd-Hrd-R MX198401780 04/01/11 04/01/12 Sch Limit 641k/10k E ICOC Zurich BR70078177 02/25/11 02/25/12 Limit 110,2001 DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES (Attach ACORD 101,Additlo al Remarks Schedule if mo spa equ ed) Certificate holder along with the City of Costa Mesa are additional insured with regards to operations of named insured for project: 17th Street Remove 8 Replace,Job#335 as per contract as per attached blanket endorsements. '10-day notice of cancellation for non-payment of premium 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. its agents and employees 628 W 19th Street AUTHORIZED REPRESENTATIVE Costa Mesa,CA 92627-2716lnn Q it ©1988-2009 A)ORD ORPORATIOON. All rights reserved. ACORD 25(2009/09) The ACORD name and logo are registered marks of ACORD Great American Assurance Company Get Construction, Inc Policy # GLP2100779 CG 20 37 Effective: 04/01/11d 07 04) THIS ENDORSEMENT CHANGES THE POLICY PLEASE READ IT CAREFULLY ADDRIONAL INSURED - OWNERS, LESSEES OR CONTRACTORS - COMPLETED OPERATIONS This endorsement mochfies insurance provided under the following COMMERCIAL GENERAL LIABLITY COVERAGE PART Schedule Name of Additional Insured Person(s) or Organlzation(sk Location and Description of Completed Operations: Blanket "As Required By Written Contract• This endorsement applies to work performed on Commercial Projects only and excludes any and all °Residential. Structures" work. 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 Itstsed the person(s) or organzation(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." /fiCopyright ISO Properties, Inc., 2004 n CG 20 37 (Ed. 07/04) PRO (Page 1 of 1) Great American Assurance Company GCI Construction, Inc CG 20 33 Policy # GLP2100779 (Ed. 07 04) Effective: 04/01/1l 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 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 person's 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 Great American Assurance Company GCI CONSTRUCTION, INC GAC 364 Policy # GLP2100779 (Ed 11 O6) Effective: 04/01/11 THIS ENDORSEMENT CHANGES THE POLICY PLEASE READ IT CAREFULLY PRIMARY CORY INSURANCE EM n" This endorsement modifies insurance provided under the following COMMERCIAL GENERAL LIABILITY COVERAGE FORM OwtERS AND CONTRACTORS PROTECTIVE LIABILITY COYEf1AGE FORM This insurance is prey 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. (-5/ � GAC 3649CG (Ed. 11/06) XS Great American Assurance Company GCI CONSTRUCTION, INC CG 24 04 Policy /4 GLP2100779 (Ed 10 93) Effective: 04/01/11 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 SCHEDULE Name of Person or Organization Blanket °As Required By Written Contract° This endorsement applies to work performed on Commercial Projects only and excludes any and all °Residential Structures° work. ( If no entry appears above information required to complete this endorsement will be shown in the Declarations as applicable to this endorsement ) The TRANSFER OF RIGHTS OF RECOVERY AGAINST OTHERS TO US Condition (Section IV Commercial General Liability Conditions ) is amended by the addition of the following 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 Urc. yrk. Copyright Insurance Services Office Inc 1992 CG 24 04 (Ed 10/93) PRO (Page 1 of 1 ) WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 0403 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 WHOM BLANKET WAIVER 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 infomration 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 $ INCL Insurance Company EVEREST NATIONAL INSURANCE COMPANY Countersigned By \ 1998 by tie waters'Compensation Insurance Rating Bureau ot Caldamia. MI rights reserved. Fran the WCIRB's California Workers'Compensation Insurance Forms Manual 1999. INSURED CCPr