Project 171 - Insurance - GCI Construction - 2008-07-14 ACORD, CERTIFICATE OF LIABILITY INSURANCE PID A SAD; oYe,
PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
Seltzer Insurance Services HOLDERR,THIS CERTIFICATE DOES NOT AMEND,EXTEND OR
140 Centennial Way ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
Tustin CA '92867
Phone 714=665-9800 Fax.714-665-9801 INSURERS AFFORDING COVERAGE NAIC#
INSURED INSURER Lexington In.. Co. LAIC Group) 19437
GCI Construction, Inc INSURERS: Granite State (AIG Group) 23809
Pact Inc.
Pacific Equipment, LLC WO C. Nat. on. rata zna Co O ar.l 19445 _
245 Fischer Ave. Ste B3 INSURERD: Redwood Fire 6 Casualty 11673
Costa Mesa CA 9226 INSURER E. Simon. Pt)/Aa.. Co. or Attar. 21873
COVERAGES ,
THE POLICIES OF INSURANCE LISTED BELDW 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
!NUR AU Et. POLICY NUMBER . S" 'el- ' E POLICY EXPIRATION
LTR NERD TYPE OF INSURANCE DATE(MWDIVYY) _DATE(MWDD/YY) LASTS
GENERAL LJABILRY EACH OCCURRENCE $1000000
A X % coIMERCIALGENERALLNBILITY 1260420 04/01/08 04/01/09 PRR ES EaONIao4ITence) :50000
CLAIMS MADE X OCCUR MED EXP(Any one person) :
—
X Owner s/Cant. Pro PERSONALSADVINJLRY S1000000
X =7/Deductible $10 000 GENERAL AGGREGATE $2000000
GENT_AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OPAGG :2000000
—1 POLICY Sn JEl-oa& n LOC 1 Emp. Ben. 1000000
AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT
B X X ANY AUTO 02-CA-009349089-0 04/01/08 04/01/09 /6a�den') $1 000 000
ALL OWNED AUTOS BODILY INJURY S
SCHEDULED AUTOS (Pet person)
X HIRED AUTOS
BODILY INJURY $
X NON-OWNED AUTOS (Peramdent)
R Comp/Coll Ded $1000 PROPERTY DAMAGE S
8 No Liab. Ded/SIR (Per accident)
GARAGE LIABILITY i AUTO ONLY EA ACCIDENT f
I ANYAUTO OTHER THAN EA ACC f
AUTO ONLY AGG S
EXCESSNMBRELLALIABAITY I EACH OCCURRENCE 54000000
C X I OCCUR I J CLAIMSMAOE BE9219788 04/01/08 04/01/09 AGGREGATE $4000000
1= S
_
DEDUCTIBLE S
RETENTION $ S
WLSIAIU- UIH-
EMPLOYSCOMPBILITY ON AND TORY LIMITS gI ER
D
EMPLOYERS'LIABILITY 4403006113-081 03/17/08 03/17/09 EL EACH ACCIDENT s1000000
ANY PROPRIETOR/PARTNER/EXECUTIVE
OFFICERA.€MBER EXCLUDED? E.L.DISEASE EA EMPLOYEE S 1000000
!z',depaibe Ialder
SPECIALPRDVLSIONSbSIfW EL DISEASE POLICYUMIT 51000000
OTHER
E IM-EcpJ /Lesd-Hrd-R MSI98401780 04/01/08 04/01/09 Sch Limit 1 8M/838k/5
COC - Zurich BR67721425 L 06/12/08 06/12/09 Limit 172095
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS
Certificate holder along with the City of Costa Mesa are additional insured
with regards to operations of named insured for project. Irvine Pumping
Station Sewer Force Main Replacement Phase 1 Mesa Drive from Irvine Ave to
Riverside Dr City of Costa Mesa as per contract as per attached blanket
endorsements *10-day notice of cancellation for non-payment of premium
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION
DATE THEREOF THE ISSUING INSURER HALL GOZZ=MAIL 30 DAYS WRITTEN
NOnCE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT Sr
Costa Mesa Sanitary District,
its agents and employees
628 W 19th Street
Costa Mesa CA 92 62 7-2 71 6 AUTHDIuzED REHRESENTA
ACORD 25(2001/08) ` I ' i'I� ® CORD ORPORATION 1988
TV€ E v
GCI Construction Inc
POLICYNUMBER ENDORSEMENT COMMERCIAL GENERAL LIABILITY
1260420 CG 20 37 10 01
THIS ENDORSEMENT CHANGES THE POLICY PLEASE READ IT CAREFULLY
ADDITIONAL_ ICED - OVWIERS, LESSEES OR
CONTRACTORS - OOIVPLETED OPERATIONS
This endorsement modifies insurance provided under the following:
COMMERCIAL GENERAL LIABILITY COVERAGE PART
SCHEDULE
Name of Person or Organization.
Blanket As Required By Written Contract
This endorsement applies to work performed on Commercial Projects only
and excludes eny and all Residential Structures work as defined by
LX 9911 (02/06) on the policy
Location And Description of Completed Operations
Additional Premium:
IIf no entry appears above, information required to complete this endorsement will be shown in the Declara-
tions as applicable to this endorsement.)
Section II Who Is An Insured is amended to include as an insured the person or organization shown in the
Schedule, but only with respect to liability arising out of "your work at the location designated and described in
the schedule of this endorsement performed for that insured and included in the products-completed
operations hazard"
CG 20 37 10 01 ®ISO Properties, Inc. 2000 Paae 1 of 1 ❑
ENDORSEMENT
This endorsement, effective 12:01 AM 04/01/2008
Forms a part of policy no. 1260420
Issued to• GCI CONSTRUCTION INC
By• LEXINGTON INSURANCE COMPANY
WAIVER OF SUBROGATION
(BLANKET)
It is agreed that we, in the event of a payment under this policy weive our right of subrogation against
any person or organization where the insured has waived liability of such person or organization as part
of a written contractual agreement between the insured and such person or organization entered into
prior to the occurrence or offense.
All other terms and conditions remain unchanged.
%-
Au orized Representative OR
Countersignature (In states where applicable)
LEXOCC234 1111031
ENDORSEMENT
This endorsement, effective 1201 AM 03/4/01 /2008
Forms a part of policy no 1260420
Issued to. GC I CONSTRUCTION I NC
By. LEXINGTON INSURANCE COMPANY
PRIMARY/NON CONTRIBUTORY ENDORSEMENT
This endorsement modifies insurance provided by the policy-
Notwithstanding any other provision of the policy to the contrary, the insurance afforded by this policy
for the benefit of the Additional Insured shall be primary insurance, but only with respect to any claim,
loss or liability arising out of the Named Insured's operations; and any insurance maintained by the
Additional Insured shall be non-contributing.
All other terms and conditions of the policy remain the same.
thori:ed Representative OR
Counters gnature (In states where applicable)
WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY FORM NUMBER
INSURER REDWOOD FIRE & CASUALTY INSURANCE COMPANY WC-99-03-06
CALIFORNIA
WAIVER OF SUBROGATION
We agree That in consideration of the additional premium charged, the Right of Subrogation Clause contained in this policy is
hereby waived as respects the following persons or entities:
Any person or organization to whom you are obligated by valid written contract wherein you have agreed to furnish
this waiver.
This endorsement applies only to those persons or entities listed in the foregoing paragraph.
The insured agrees to maintain contract records in order to determine for which jobs this waiver will apply.That information will
be verified by the insurer at final audit
A surcharge of 1% shall be applied to the risk's Standard Premium, subject to a minimum charge of$500, and will be collected
upon completion of the final audit
This endorsement changes the policy to which it Is attached and Is effective on the date Issued unless otherwise stated.
(The Information below Is required only when this endorsement Is Issued subsequent to preparation of the policy.)
Endorsement Effective: 03/17/2008 Policy No. 4403008113-081 Endorsement No. 1
Insured: GC!CONSTRUCTION, INC.(A CORP)
insurance Company Countersigned by.Redwood Fire And Casually Insurance Company