Project 181 - Insurance - Nikola - 2007-03-23 ACORD CERTIFICATE OF LIABILITY INSURANCE OP ID DATE(MM/DD/YYYY)
NI CHO-1 03/23/07
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.
COSTA MESA CA 92626
Phone 714r444-2679 Fax 714-444-17 E
CE-PV
D INSURERS AFFORDING COVERAGE NAIC#
INSURED L. L INSURERA Gemini Insurance Company
Nikola Construction 2 8 2007 INSURER B. state cmq+eneati Ins. Fund
Corporation MAR
DBA: Nikola Corporation INSURER C: QBE Specialty
18012
rvin Cowan, to 290 CUST MESA oAflU RV�ISiR IIFSURER D: United National Insurance co
NSURER 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
p POLICY EFFECTIV POLICY EXPIRATION
ILTR rata' TYPE OF INSURANCE POLICY NUMBER DATE(MWDD/YY) DATE(MWDDNY) LIMITS
GENERAL LABILITY EACH OCCURRENCE $ 1,000,000
A X X COMMERCIAL GENERAL LIABILITY VCGP013092 08/15/06 08/15/07 PREMISES(Ea $ 50,000
CLAIMS MADE X OCCUR MEDEXP(Any eperson) $ 5,000
X Blanket Addl Insd PERSONAL BADV INJURY $ 1,000,000
X Waiver of Subro GENERAL AGGREGATE $2,000,000
GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG s2,000,000
—
PRO-
POLICY LOC
JECT
AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $
(Ea accident)
ANY AUTO
ALL OWNED AUTOS BODILY INJURY $
(Per person)
SCHEDULED AUTOS
HIRED AUTOS BODILY INJURY $
(Pe accident)
NON-OWNED AUTOS _ —
PROPERTY DAMAGE $
(Pe accident)
GARAGE LIABILITY AUTO ONLY EA ACCIDENT $
ANY AUTO OTHER THAN EA ACC 5
AUTO ONLY' AGG $
EXCESS/UMBRELLA LIABILITY EACH OCCURRENCE $ 5,000,000
C X IOCCUR CLAIMS MADE FCX0004549 03/15/07 06/01/07 AGGREGATE $ 5,000,000
$
DEDUCTIBLE
X RETENTION $10,000 $
WCSIAIU- UIH-
WORKERS COMPENSATION AND X TORY LIMITS ER
B
EMPLOYERS'LIABILITY 046-12549-2005 12/24/06 12/24/07 ELEACHACCIDENT $ 1,000,000
ANY PROPRIETOR/PARTNER/EXECUTIVE E L DISEASE EA EMPLOYEE S 1 000,000
OFFICER/MEMBER EXCLUDED? r
SPECALPROVISIONS below EL DISEASE POLICY LIMIT $ 1,000,000
OTHER
C Leased Borrowed, 2598480 07/10/06 07/10/07 Contrs EQ $100 000
Rented Equipment 2% ded $5,000 max
DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS
Certificate holders & its officers agents and employees are named as
additional insured per the Blanket Additional insured Endorsement VE0182 03
04 with respect to Costa Mesa Sanitary District Project #181-Newport Blvd
Sewer at 19th St & Placentia Ave Sewer at 18th Street Waiver of Subro-
gation Endorsement applies *except 10 days for nonpay REPLACES PRIOR CERT
CERTIFICATE HOLDER CANCELLATION
COST SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION
Costa Mesa Sanitary District DATE THEREOF THE ISSUING INSURER WILL ENO€*VOR TO MAIL 30* DAYS WRITTEN
Joan Revak, Board Secretary NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT &Tc.Dn3DSNALL
FAX 949-650-2253 IMPO NOOBL : . • . .
628 W 19th Street � .,
Costa Mesa CA 92627 A ED REPR T g
ACORD 25(2001108) m ACORD CORPORATION 1988
Policy Number VCGP013092 VE 0182 03 04
Insured Name:NIKOLA CONSTRUCTION CORP
DBA. NIKOLA CORPORATION
Number 32 Effective Date:08/15/2006
THIS ENDORSEMENT CHANGES THE POLICY PLEASE READ IT CAREFULLY
BLANKET ADDITIONAL INSURED ENDORSEMENT
This endorsement modifies insurance provided under the following:
COMMERCIAL GENERAL LIABILITY COVERAGE PART
PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE PART
A. Section II—Who is An Insured is amended to include as an insured any person or
organization for whom you are performing operations when you and such person or
organization have agreed in writing in a contract or agreement that such person or
organization be added as an additional insured on your policy Such person or organization is
an additional insured but only with respect to liability caused by your ongoing operations
performed for that insured. A person's or organization's status as an insured under this
endorsement ends when your operations for that insured are completed. This insurance does
not apply to liability caused by the sole negligence of any additional insured.
B. With respect to the insurance afforded to these additional insureds, the following additional
exclusions applies:
This insurance does not apply to:
I The preparing, approving, or failing to prepare and approve,maps, shop drawings,
opinions,reports, surveys, field orders, change orders or drawings and specifications; and
2. Supervisory inspection,architectural or engineering activities.
VE 0182 03 04 Page I of 1
Policy Number VCGP013092 CG 24 0410 93
Insured Name:NIKOLA CONSTRUCTION CORP DBA.NIKOLA CORPORATION
Number 33 Effective Date:08/15/2006
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:
AS 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.
CC 24 04 10 93 Copyright,Insurance Services Office,Inc. 1992 Page 1 of ❑