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Insurance - Paulus - 2009-07-28 44 OR0® . CERTIFICATE OF LIABILITY INSURANCE OP ID JR DATE(MM/ODmrY) o7/26/D9 PRODUCER THIS THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION a The Wooditch Company Insurance 66 }ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE 1 Park Services Plaza, Suite 400 R E C E 1 V E LoALLTER THEHCOVERAGE A FORDED BOYT HE POLIO ES BELOW. Irvine CA 92614 Phone 949-553-9800 Fax 949-553-051A - 6 2009 INSURERSAFFORDINGCOVERAGE NAIC# INSURED Il'��1! 2ER A' Old Republic Goner I S. Corp A—/k 24139 COS1 MESA SANITARY DIST TER B Una n Fire Ins. Co $_ X✓ 19445 Paulus Engineering Inc INSURER C I 2871 E Coronado Street INSURERD Anaheim, CA 92806 I INSURER E I COVERAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH 1g5PPOLLIICIE1S AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS LTRINSRd TYPE OF INSURANCE POLICY NUMBER POLICMM/DDTY IVE DATE(MM/DIRATION I POLICY EFFECTIVE POLL POLICY EXPIRATION LIMITS GENERAL LIABILITY EACH OCCURRENCE I$ 1,000,000 A X X COMMERCIAL GENERAL LM A1CG94840900 05/01/09 05/01/10 PREMISES(EaEoccurence) $ 100,000 CLAIMS MADE X OCCUR MED EXP(Any Pe n) $5,000 PERSONAL BADV INJURY S 1,000,000 GENERAL AGGREGATE $2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER PRODUCTS COMP/OP AGG $2,000,000 POLICY IA PRO-CT n LOC JE AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT S1 000 000 A X ANY AUTO A1CA94840900 05/01/09 05/01/10 (Eaacadent) ALL OWNED AUTOS BODILY INJURY $ SCHEDULED AUTOS Per person) HIRED AUTOS BODILY INJURY $ NON-OWNED AUTOS (Pe amdenl) PROPERTY DAMAGE $ (Pe accident) GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $ ANY AUTO OTHERTHAN EA ACC I$ AUTO ONLY AGG I$ EXCESS/UMBRELLA LIABILITY EACH OCCURRENCE $5,000,000 B 7{]OCCUR CWMSMADE BE012049502 05/01/09 05/01/10 AGGREGATE 1$5,000,000 $ DEDUCTIBLE $ X RETENTION 510,000 I$ WORKERS COMPENSATION X Wt.bIAIU- OIH AND EMPLOYERS'LABILITY A ANY PROPRIETOR/PARTNER/EXECUTNCIYI N A1CW94840900 05/01/09 05/01/10 EL EACH ACCIDENT $ 1,000,000 (Mandatory In NH) EXCLUDED? I EL DISEASE EA EMPLOYEE S 1,000,000 If(Myes,detente ry in NH) SPECIAL PROVISIONS below EL DISEASE POLICY LIMIT $ 1,000,000 OTHER DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS *Except 10 days notice of cancellation for non-payment of premium RE Paulus Job #926 CMSD Job #129 Bristol Street Sewer Replacement Costa Mesa Sanitation District and its employees and agents are named as Additional Insureds as respects General Liability per attached endorsement *SEE NOTES* glaipwv(comp)/auwv/wcwv/x CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION COSTAM4 DATE THEREOF THE ISSUING INSURER WILL OYBelYYi'MAIL 30 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, - , Costa Mesa Sanitation District UTH nraaaaaie^ 628 W 19th Street RUTH RESENTATNE Costa Mesa CA 92627 ACORD 25(2009/01) 8- 0 9 A RD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD IMPORTANT If the certificate holder is an ADDITIONAL INSURED the policy(ies) must be endorsed. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). 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). DISCLAIMER This Certificate of Insurance does not constitute a contract between the issuing insurer(s), authorized representative or producer and the certificate holder nor does it affirmatively or negatively amend, extend or alter the coverage afforded by the policies listed thereon. 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This Insurance shall apply as Primary and Non-Contributory per attached endorsement Waiver of Subrogation for General and Auto Liability and Workers Compensation See Attached Endorsements POLICY NUMBER:Al CG94840900 COMMERCIAL GENERAL LIABILITY CG 20 37 07 04 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) Location And Description Of Completed Or Organization(s): Operations Blanket as required by contract As specified in your signed and written ANY PERSON OR ORGANIZATION FOR WHOM agreement in advance of the 'occurrence"for THE NAMED INSURED IS REQUIRED UNDER which the additional insured seeks coverage WRITTEN CONTRACT TO FURNISH THIS ENDORSEMENT Information required to complete Ihs Schedule,if nrn shown alcove,wdl be shown n the Declarauons. Section II 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' 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' CO 20 '7 07 04 Copyright. Insunma.Sen ices OrfiL Ira 2004 Paee I of I POLICY NUMBER: A1CG94840900 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 Organization(s): Location(s) Of Covered Operations As specified in your signed and written WHERE REQUIRED BY WRITTEN CONTRACT agreement in advance of the "occurrence" Any person or organization for whom the named for which the additional insured seeks insured is required under written contract coverage to furnish this endorsement Information required to complete this Schedule, if not shown above,will be shown In the Declarations. A. Section II — Who Is An Insured is amended to B. With respect to the insurance afforded to these include as an additional insured the person(s) or additional insureds, the following additional exclu- organization(s) shown in the Schedule, but only sions apply: with respect to liability for 'bodily injury' "property This insurance does not apply to 'bodily injury" or damage or 'personal and advertising injury" 'property damage' occurring after: caused, in whole or in part, by' 1. All work, including materials, parts or equip- 1 Your acts or omissions; or ment furnished in connection with such work, 2. The acts or omissions of those acting on your on the project (other than service, mainten- behalf; ance or repairs) to be performed by or on be- in the performance of your ongoing operations for half of the additional insured(s) at the location the additional insured(s) at the location(s) desig- of the covered operations has been completed; nated above. 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 other than another contractor or subcontractor en- gaged in performing operations for a principal as a part of the same project. CG 20 10 07 04 0 ISO Properties, Inc. 2004 Page 1 of 1 ❑ OLD REPUBLIC GENERAL INSURANCE CORPORATION CHANGES ADDITIONAL INSURED PRIMARY WORDING SCHEDULE THIS ENDORSEMENT CHANGES THE POLICY PLEASE READ IT CAREFULLY THIS ENDORSEMENT MODIFIES INSURANCE PROVIDED UNDER THE FOLLOWING: COMMERCIAL GENERAL LIABILITY COVERAGE FORM Name of Additional Insured Person(s) Location(s) of Covered Operations Or Organization(s): Blanket as required by contract As specified in your signed and written agreement ANY PERSON OR ORGANIZATION FOR WHOM THE in advance of the 'occurrence"for which the NAMED INSURED IS REQUIRED UNDER WRITTEN additional insured seeks coverage CONTRACT TO FURNISH THIS ENDORSEMENT As required by written contract: Information required to complete this Schedule, if not shown above, will be shown in the Declarations. The insurance provided by this endorsement is primary insurance and we will not seek contribution from any other insurance of a like kind available to the person or organization shown in the schedule above unless the other insurance is provided by a contractor other than the person or organization shown in the schedule above for the same operation and job location. If so, we will share with that other insurance by the method described in paragraph 4.c. of Section IV—Commercial General Liability Conditions. All other terms and conditions remain unchanged. Named Insured Paulus Engineering, Inc. Policy Number Al CG94840900 Endorsement No. Policy Period 05/01/2009-05/01/2010 Endorsement Effective Date: 05/01/2009 CG EN GN 0029 (09/06) POLICY NUMBER: AlCG94840900 COMMERCIAL GENERAL LIABILITY CG 24 04 10 93 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: WHERE REQUIRED BY WRITTEN CONTRACT (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. CG 24 04 10 93 Copyright, Insurance Services Office, Inc. 1992 Page 1 of 1 ❑ OLD REPUBLIC GENERAL INSURANCE CORPORATION WAIVER OF TRANSFER OF RIGHTS OF RECOVERY AGAINST OTHERS TO US THIS ENDORSEMENT CHANGES THE POLICY PLEASE READ IT CAREFULLY THIS ENDORSEMENT MODIFIES INSURANCE PROVIDED UNDER THE FOLLOWING' BUSINESS AUTO COVERAGE FORM The following is added to Section IV—Business Auto Conditions,A.—Loss Conditions,5.—Transfer of Rights of Recovery Against Others to Us. However we will waive any right of recovery we have against any person or organization with whom you have entered into a contract or agreement because of payments we make under this Coverage Form arising out of an accident"or"loss if (1) The accident"or loss is due to operations undertaken in accordance with a Written contract existing between you and such person or organization:and (2) The contract or agreement was entered into prior to any"accident' or"loss. No waiver of the right of recovery will directly or indirectly apply to your employees or employees of the person or organization, and we reserve our rights of lien to be reimbursed for any recovery funds obtained by any injured employee. Named Insured Paulus Engineering, Inc. Policy Number A1CA94840900 Endorsement No Policy Period 05/01/2009-05/01/2010 Endorsement Effective Date. 05/01/2009 Producers Name: The Wooditch Company Producer Number. CA EN GN 0021 09 06 OLD REPUBLIC GENERAL INSURANCE CORPORATION WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT THIS ENDORSEMENT CHANGES THE POLICY PLEASE READ IT CAREFULLY THIS ENDORSEMENT MODIFIES INSURANCE PROVIDED UNDER THE FOLLOWING. WORKERS COMPENSATION AND EMPLOYERS' LIABILITY INSURANCE 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. This agreement shall not operate directly or indirectly to benefit anyone not named in the Schedule. Schedule Name of Additional Insured Person(s)or Organization(s)• Blanket as required by contract ANY PERSON OR ORGANIZATION FOR WHOM THE NAMED INSURED IS REQUIRED UNDER WRITTEN CONTRACT TO FURNISH THIS ENDORSEMENT Location(s) of Covered Operations: As specified in your signed and written agreement in advance of the 'occurrence for which the additional insured seeks coverage The premium charge for this endorsement is $0.00 Named Insured Paulus Engineering, Inc. Policy Number A1CW94840900 Endorsement No. Policy Period 05/01/2009—2010 Endorsement Effective Date: 05/01/2009 WC 990315 (09/06)