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Insurance - Southwest - 2011-12-19
OP ID: RG '40RO CERTIFICATE OF LIABILITY INSURANCE DATE 12/19O/YYYY 12119111 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 CT 949-553-9800 NAME: The Wood itch Company Insurance 949-553-0670 PHONE FAX Services,Inc. _(ac,No,Eat): Sac,No): 1 Park Plaza,Suite 400 E-MAIL ADDRESS: Irvine,CA 92614 PRODUCER Jamie Younger CUSTOMER ID p'COLIC-1 INSURER(S)AFFORDING COVERAGE NAIL INSURED Southwest Pipeline v" Alpo@y old Republic General Ins.Corp A j X 24139 and Trenchless Corp. ✓ hopr .National Union Fire Ins.Co. A X V 19445 547 W 140th Street Gardena, CA 90248 INSURER C INSURER D. INSURER E 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 TYPE OF ADDLISUBR POLICY EFF POLICY EXP LIMITS LTR IN RI WV()I POLICY NUMBER (MMIDDIYYYYI IMMIDDIYYYYI GENERAL LIABILITY EACH OCCURRENCE g 1,000,000 A X COMMERCIAL GENERAL LIABILITY X X A1CG00581103 06/01/11 06/01/12 rREvig OERa EoNcwrD rencel $ 100,000 CLAIMS-MADE X OCCUR MED EXP(Any on person) $ 5,000 PERSONAL&ADM INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER PRODUCTS-COMP/OP AUG $ 2,000,000 POLICY A PRO- n LOC $ JECT AUTOMOBILE LIABILITY X X COMBINED SINGLE LIMIT $ 1,000,000 V A X ANY AUTO A1CA00581103 06/01/11 06/01/12 BODILY BODILY INJURY(Pe pe n) $ ALL OWNED AUTOS BODILY INJURY(Pe accident) $ SCHEDULED AUTOS PROPERTY DAMAGE $ HIRED AUTOS (Pe accmde y NON-OWNED AUTOS X UMBRELLA LIAR X OCCUR EACH OCCURRENCE $ 1,000,000 EXCESSLIAB CLAIMS-MADE AGGREGATE 1 1,000,000 B BE86308542 10/15/11 06/01/12 DEDUCTIBLE S X RETENTION S 10,000 1 WORKERS COMPENSATION X TORYTATUS 01- PI-ANO EMPLOYERS'LIABILITY A ANYIPROPRIEBO� %RTNER/E ECUTIVE YIN NIA X A1CW93331102 06/01/11 06/01/12 EL EACH ACCIDENT $ 1,000,000 (Manda Dry NH) E L DISEASE EA EMPLOYEE $ 1,000,000 If yes,describe under DESCRIPTION OF OPERATIONS belox E L DISEASE POLICY LIMIT $ 1,000,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (Attach ACORD 101,Addltlo al Remarks Schedule If no spa Is required) *Except 10 Days Notice of Cancellation for Non-Payment of Premium. RE:SWP&T Job#651;SPI#312;#164 Root Control Program. Costa Mesa Sanitary District,its employees and agents,and Contractor are included as Additional Insureds as respects General and Auto Liability,per attached endorsements. `SEE NOTES** glaipwvlauaiwv/wcwv CERTIFICATE HOLDER CANCELLATION COSTAME 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. 628 W. 19th Street Costa Mesa,CA 92627 AUTHORIZED REPRESENTATIVE ©1988-2009 ACORD CORPORATION. All rights reserved. ACORD 25(2009/09) The ACORD name and logo are registered marks of ACORD coca, 196E 2 NOTEPAD INSUREDS NAME Southwest Pipeline OP ID: RG DATE 12119111 *Should this policy be cancelled before the expiration date The Wooditch Company will mail 30(thirty)days written notice to those Certificate Holders which require such action per contract or agreement.* • NOTEPAD. HOLDER CODE COSTAME COLIC-1 PAGE$ INSURED'S NAME Southwest Pipeline OP ID: RG DATE 12/19111 This Insurance shall apply as Primary and Non-Contributory per attached endorsement. Waiver of Subrogation for Workers Compensation,General Liability,and Auto Liability. See Attached Endorsements. POLICY NUMBER: AlCG00581103 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 WHERE REQUIRED BY WRITTEN CONTRACT 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 insureds) 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 anses 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 © ISO Properties, Inc. 2004 Page 1 of 1 ❑ POLICY NUMBER: A l CG00581 103 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 Opera- Or Organization(s): tions WHERE REQUIRED BY WRITTEN CONTRACT BUT ONLY WHEN COVERAGE FOR COMPLETED OPERATIONS IS SPECIFICALLY REQUIRED BY THAT CONTRACT 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 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' CG 20 37 07 04 © 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): 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 Southwest Pipeline R. Trenchiess Corp. Policy Number A1CC;005R110, Endorsement No Policy Period 06/01/2011 to Endorsement Effective Date: 06/01/2011 06/01/2012 Producer's Name: Producer Number AUTHORIZED REPRESENTATIVE DATE CG EN GN 0029 09 06 POLICY NUMBER: AICG00581103 COMMERCIAL GENERAL LIABILITY CG 24 04 05 09 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: WHERE REQUIRED BY WRITTEN CONTRACT 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. CG 24 04 05 09 © Insurance Services Office, Inc. 2008 Page 1 of 1 ❑ OLD REPUBLIC GENERAL INSURANCE CORPORATION ADDITIONAL INSURED WHERE REQUIRED UNDER CONTRACT OR AGREEMENT 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 II —Liability Coverage, A. —Coverage 1 Who Is An Insured: d. Any person or organization to whom you become obligated to include as an additional insured under this policy as a result of any contract or agreement you enter into which required you to furnish insurance to that person or organization of the type provided by this policy but only with respect to liability arising out of your operations or premises owned by or rented to you. However the insurance provided will not exceed the lessor of 1 The coverage or limits of this policy or 2. The coverage or limits required by said contract or agreement. Named Insured Southwest Pipeline & Trenchless Corp. Policy Number A]CA00581 103 Endorsement No Policy Period 06/01/2011 to Endorsement Effective Date: 06/01/9011 06/01/2012 Producer's Name: Producer Number AUTHORIZED REPRESENTATIVE DATE CA EN GN 0020 03 07 POLICY NUMBER: Al CA00581103 COMMERCIAL AUTO CA 04 44 03 10 THIS ENDORSEMENT CHANGES THE POLICY PLEASE READ IT CAREFULLY WAIVER OF TRANSFER OF RIGHTS OF RECOVERY AGAINST OTHERS TO US (WAIVER OF SUBROGATION) This endorsement modifies insurance provided under the following: BUSINESS AUTO COVERAGE FORM BUSINESS AUTO PHYSICAL DAMAGE 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 the endorsement. This endorsement changes the policy effective on the inception date of the policy unless another date is indicated below Named Insured: Southwest Pipeline & Trenchless Corp Endorsement Effective Date: 06/01/2011 SCHEDULE Name(s)Of Person(s) Or Organization(s): Where required by written contract. Information required to complete this Schedule, if not shown above,will be shown in the Declarations. The Transfer Of Rights Of Recovery Against Oth- ers To Us Condition does not apply to the person(s) or organization(s) shown in the Schedule, but only to the extent that subrogation is waived prior to the "ac cadent' or the 'loss' under a contract with that person or organization. CA 04 44 03 10 ©Insurance Services Office, Inc. 2009 Page 1 of 1 ❑ OLD REPUBLIC GENERAL INSURANCE CORPORATION WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY 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. 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 WHEN REQUIRED BY WRITTEN CONTRACT The premium charge for this endorsement is $0.00 Named Insured Southwest Pipeline & Trenchless Corp. Policy Number Al CW93331102 Endorsement No. Policy Period 06/01/2011 to Endorsement Effective Date: 06/O1;2011 06/01/2012 Producer's Name: Producer Number AUTHORIZED REPRESENTATIVE DATE WC 99 03 15(01/07)