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Insurance - Nikola - 2010-10-04 I. ACORD_ CERTIFICATE OF LIABILITY INSURANCE OP ID DATEi /04/ 0 NICHO-1 10/04/10 ,_ PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE CLARKE MARINE INSURANCE HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR 245 FISCHER AVENUE, SUITE D-8 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. — "OSTA MESA CA 92626 \ 'hone 714-444-2679 Fax 714-444-0176 INSURERSAFFORDINGCOVERAGE NAIC# — INSURED INSURERA QBE Specialty Insurance Co _ Nikola Construction INSURER B: Evanston Insurance Co ' Corporation INSURER C. e�m c�y.n,eve nsuranm DBA- Nikola Corporation .— 18012 Cowan Suite 290 INSURER Dr Century Surety Insuranee Co Irvine CA 91614 '- INSURER E _ 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 POLICIES.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. ILTRy1UU POLICY NUMBER POLICY E TWE 'P&ICYtRPIWATISW LIMBS LTRINSR[ TYPE OF INSURANCE (MWODDY) OATS(MMIDOM') — GENERAL LIABILITY EACH OCCURRENCE I S I;000,000 _ A X X COMMERCIALGENER�ALLNBIIJTY GXG00722 08/15/10 08/15/11 PREABSESS((ERaEmmurem) 1550,000 CLAIMSMADEInlOCCUR MEDEXP(Any one Person) I3 5,000 — X Blanket Addl Insd PERSONAL AADVINJURY x1,000,000 X Waiver of Subro GENERALAGGREGATE $2,000,000 GEM.AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG s 2;000,000 _— —1 POLICY IA I'28 r'.. I LI I LOC ,- AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT ANY AUTO Na auidenl) S .- ALL OWNED AUTOS BODILY INJURY S • SCHEDULED AUTOS (Per person) HIRED AUTOS BODILY INJURY S NON-OWNED AUTOS (Per accident) • PROPERTY DAMAGE S (Per amdenu) GARAGE LIABILITY AUTO ONLY EA ACCIDENT S \• EA ACC S ANY AUTO OTHER THAN AUTO ONLY: AGG S EXCESS/UMBRELLA IJABILNY EACH OCCURRENCE $2;000,000 B X ]OCCUR CLAIMS MADE XOWE22801O 08/15/10 08/15/11 AGGREGATE $2,000,000 $ DEDUCIBLE S X RETENDON $3.0000 $ .- X Ira Y UNITS 1 ER EMPLOYSCONPEILJTY AND — C EMPLOrERSLNABNLm 1886603-2009 12/24/09 12/24/10 ELEACHACCIDENT x1,000,000 ANY PROPRIETORIPARTNER/EXECUTIVE — OFFICER/MEMBER EXCLUDED? EL.DISEASE EA EMPLOYEE S 1,000,000 _ I yyeeaa AL PROVISIONS EL DISEASE POLICY LIMIT $1,000,000 SPECIAL PROVISIONS below .- OTHER D Excess Liability TO FOLLOW 10/04/10 08/15/11 Per Occur $2 000 00(I $10,000 SIR Genl Aggr $2,000,00C_ DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS Certificate holders are named as an additional insured with respect to Contract #183-2 Bristol Street Sewer n/o Randolph Ave and per Blanket Additional Insured Endorsement no CG 2010 07/04 Coverage is primary S non contributory to any other insurance *except 10 day notice of cancellation for non payment CERTIFICATE HOLDER CANCELLATION COSTAME SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRAT')N Costa Mesa Sanitary District & DATE THEREOF THE ISSUING INSURER WILLIMffifflin MAIL 30* DAYS WRITTEI. it s employees & agents NOTICE TO TIE CERTIFICATE HOLDER NAMED TO THE LEFT. Attn Robin Hamers D E I . 628 W 19th Street Costa Mesa CA 92627-2716 weessennms.. ,..._I...• A W REPR TpE7 ACORD 25(2001/08) 0 ACORD CORPORATION 1938 POLICY NUMBER: GXG00722 COMMERCIAL GENERAL LIABILITY CG 2010 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 Costa Mesa Sanitary District & it's Contract#183-2 Bristol Street Sewer employees & agents nit Randolph Avenue Attn: Robin Hamers, D.E. 628 W 19th Street Costa Mesa, CA 92627-2716 Information required to complete this Schedule,if not shown above,will be shown in the Declarations. A. Section 11 — 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, maintenance behalf; or repairs) to be performed by or on behalf of in the performance of your ongoing operations for the additional insured(s) at the location of the the additional insured(s) at the location(s) desig- covered operations has been completed;or nated above. 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 ©ISO Properties, Inc. 2004 Page 1 of 1 ❑