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Insurance - GEO-ETKA - 2010-11-01 POLICYHOLDER COPY -. ._. .y:.. SP S,TATE COMPENSATION . P.O. BOX 420807 SAN FRANCISCO,CA 94142-0807 I N S U R A N C E' ' F.0 N CERTIFICATE OF WORKERS' COMPENSATION INSURANCE ISSUE DATE 11-01 2010 GROUP. POLICY NUMBER: 0682097 2010 CERTIFICATE ID: 187 CERTIFICATE EXPIRES: 11-01 2011 11-01 2010/11-01 2011 COSTA MESA SANITARY DISTRICT SP 628 W 19TH ST COSTA MESA CA 92627 2716 This is to certify that we have issued a valid Workers Compensation insurance policy in a form approved by the California Insurance Commissioner to the employer named below for the policy period indicated. This policy Is not subject to cancellation by the Fund except upon 30 days advance written notice to the employer We will also give you 30 days advance notice should this policy be cancelled prior to its normal expiration. This certificate of insurance is not an insurance policy and does not amend, extend or alter the coverage afforded by the policy listed herein. Notwithstanding any requirement, term or condition of any contract or other document with respect to which this certificate of insurance may be issued or to which it may pertain, the insurance afforded by the policy described herein is subject to all the terms, � _ exclusions, and conditions, of such policy. Authorized Representative President and CEO EMPLOYER S LIABILITY LIMIT INCLUDING DEFENSE COSTS $1 000 000 PER OCCURRENCE ENDORSEMENT 42065 ENTITLED CERTIFICATE HOLDERS NOTICE EFFECTIVE 11-01 2004 IS ATTACHED TO AND FORMS A PART OF THIS POLICY EMPLOYER GEO-ETKA, INC SP 739 N MAIN ST ORANGE CA 92868 IP 18,SPI PRINTED 02-09 2011 (REV.8-20101 A� IY CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDDYY) 11/4/2010 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 CONTACT Wanda Jew NAME: PHONE (714)221-3900 FAX ro,_k U Alc,Nog(714)221-227 Business & Insurance Services E-MAIL DRESS 2127 W Orangewood Suite 100 cu°sT°OMERID#00001221 Orange CA 92868 INSURER(S)AFFORDING COVERAGE NAILS INSURED INSURERA:Hartford Casualty Insurance Co. INSURER B:Prop & Cas. Ins Co of Hartford GEO-ETKA, Inc INSURERC. 739 N Main Street INSURERD. _ INSURER E _ Orange CA 92868 INSURERF. COVERAGES CERTIFICATE NUMBER:10-11 All Lines 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 'ADBcstBR POLICY EFF POLICY EXP LIMITS LTR TYPE OF INSURANCE INSR WVD POLICY NUMBER (MMIDDIYYYY) (MMIDDIYYYY) GENERAL UABILITY EACH OCCURRENCE $ 1,000,000 DAMAGE TO RENTED 300,000 X COMMERCIAL GENERAL LIABILITY PREMISES(Ea occurr e) $ A __ CLAIMS-MADE X OCCUR 72SBAUW0690 11/6/2010 11/6/2011 MED EXP(Any one person) $ 10,000 PERSONAL 8ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GE 'L AGGREGATE LIMIT APPLIES PER PRODUCTS-COMP/OP AGG $ 2,000,000 PRO- X POLICY FCT LOC _ $ AUTOMOBILE OABIUTY COMBINED SINGLE LIMIT $ 1 000 000 (Ea ()dent) X ANY AUTO BODILY INJURY(Per pa sa) $ B ALL OWNED AUTOS 72UECKB2507 11/6/2010 11/6/2011 BODILY INJURY(Pe orient) $ SCHEDULED AUTOS PROPERTY DAMAGE HIRED AUTOS (Pe °dent) $ NON-OWNED AUTOS Un red molaist property $ Un red moto st BI split lima $ X UMBRELLAUAB OCCUR EACH OCCURRENCE 2,000,000 EXCESS LIAB X CLAIMS-MADE AGGREGATE $ 2,000,000 DEDUCTIBLE A X ' RETENTION $ 10,000 72SBAUWO690 11/6/2010 11/6/2011 WORKERS COMPENSATION AND EMPLOYERS'LIABILITY YIN TORY LIMITS ER ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED' N I A (Mandatory- NH) EMPLOYE It ye..,describe under • POLICY DESCRIPTION OF OPERATIONS blow , DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES(Attach ACORD 101,Addibpnal Remarks Schedule if more spa Is equlred) *30 days written notice of cancellation except 10 days for non-payment of premium. Certificate Holder Costa Mesa Sanitary District named additional insured where required by written contract. CERTIFICATE HOLDER CANCELLATION RBHINC@ Pacbel l net SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Costa Mesa Sanitary District 628 West 19th Street Costa Mesa CA 92627 AUTHORIZED REPRESENTATIVE -f-I=, Dan Armstrong/MRAMO ACORD 25(2009/09) ©1988-2009 ACORD CORPORATION. All rights reserved. INS025(200909) The ACORD name and logo are registered marks of ACORD