Project 161 - Insurance - Atlas-Allied - 2002-05-24 Client# . 32903 ATLAALL
ACORDT. CERTIFICATE OF LIABILITY INSURANCE 05/24/02
PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
Armstrong/Robitaille Bus&Ins Sv ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
680 Langsdorf Drive Suite 100 HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
g ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
PO Box 34009
Fullerton CA 92834-9409 INSURERS AFFORDING COVERAGE
INSURED INSURERA Royal Surplus Lines Insurance
Atlas Allied Inc INSURERS CNA/American Cas Co of Reading PA
1210 N Las Brisas INSURERC Constitution Insurance Co
Anaheim CA 92806 INSURERD State Compensation Insurance Fund
I INSURERS CNA/Nat' 1 Fire Ins of Hartford
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
INSR TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATION LIMITS
LTR DATE(MM/DD/YY) DATE(MM/DD/YY)
A GENERAL LIABILITY KZ3518549 11/01/01 11/01/02 EACH OCCURRENCE $1, 000, 000
X COMMERCNL GENERAL LIABILITY FIRE DAMAGE(Any eh e) $50/ 000
CLAIMS MADE X OCCUR MED EXP(Any person) $0
BI/PD Ded. 2, 500 PERSONAL 8 ADV INJURY $1, 000, 000
GENERAL AGGREGATE $2 , 000 , 000
GEN'L AGGREGATE LIM IT APPLIES PER: PRODUCTS •COMP/OP AGG $1, 000 000
POLICY I X I JEC I LOC
B AUTOMOBILE LIABILITY BUA1010931884 11/01/01 11/01/02 COMBINED SINGLE LIMIT
X ANY AUTO (Ea °dent) $1 000 0 0 0
ALL OWNED AUTOS BODILY INJURY
SCHEDULED AUTOS (Per person) $
X HIRED AUTOS
BODILY INJURY $
X NON-OWNED AUTOS (Pe cldenp
PROPERTY DAMAGE $
(Pe dent)
GARAGE LIABILITY AUTO ONLY EA ACCIDENT $
ANY AUTO
OTHER THAN
AUTO ONLY EA ACC $AGG S
C EXCESS LIABILITY CUL41383 11/01/01 11/01/02 EACH OCCURRENCE
s4 , 000, 000
OCCUR CLAIMS MADE AGGREGATE $4 000, 000
$
DEDUCTIBLE $
RETENTION $ $
D WORKERS COMPENSATIONAND 31972 11/01/01 11/01/02 X TpRYLAMITS I IGER
EMPLOYERS'LIABILITY E.L.EACH ACCIDENT $1 , 000, 000
E L.DISEASE-EA EMPLOYEE $1 , 000 000
EL DISEASE POLICY LIMIT $1 , 000/ 000
E 1 OTHER Installation TCP1010931870 11/01/01 11/01/02
(Floater $500 000 limit
1 $500 deductible
DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS
30 Day Notice of Cancellation Except for 10 Day Non-pay of Premium
Re project# 1112100-161 Water Services for Sewer Pump Station
Costa Mesa Sanitary District and its employees are added as additional
insured for the above project Waiver of subrogation for General Liability
(See Attached Descriptions)
CERTIFICATE HOLDER 1 I ADDDIONAL INSURED;INSURER LETTER: CANCELLATION
' SHOULD ANYOFTH E ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION
Costa Mesa Sanitary District DATE THEREOF THE ISSUING INSURER WILL SERDBARAXEIAIL 30 DAYS WRITTEN
Clerk of the District NOTICE TOTHE CERTIFICATE H OLD ER NAM ED TO TH E LEFL,$DITAXPpLXjDpBQ}pp¢Dpt
PO Box 12 0 0 xOCKIKONTAXIM DIEIoKIRMBELS ESKUR PRIMILIK e y IB
Costa Mesa CA 92660-1200 BER.BOCIGATOBZ$K
AUTHORIZED ESENTATIVE
ACORD 25-S(7/97)1 Of 3 #S170326/M155179 CIK 0 ACORD CORPORATION 1988
DESCRIPTIONS (Continued from Page 1)
applies per attached endorsement Waiver of subrogation for Work Comp
applies endorsement to be issued by carrier This insurance is Primary &
non-contributory Admitted carrier/cut-thru endorsement to be issued by
carrier
AMS25.3(07/97) 3 of 3 #S170326/M155179
POLICY NUMBER: KZB518549 COMMERCIAL GENERAL LIABILITY
ATLAS-ALLIED INC.
THIS ENDORSEMENT CHANGES THE POLICY PLEASE READ IT CAREFULLY
ADDITIONAL INSURED - OWNERS, LESSEES OR
CONTRACTORS - (FORM B)
This endorsement modifies insurance provided under the following
COMMERCIAL GENERAL LIABILITY COVERAGE PART
SCHEDULE
Name of Person or Organization:
COSTA MESA SANITARY DISTRICT
Job Description: JOB# 1112100-161 WATER SERVICES FOR SEWER PUMP STATION
(If no entry appears above, information required to complete this endorsement will be shown in the Declarations as
applicable to this endorsement.)
WHO IS AN INSURED (Section II) 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' for that insured by or for you
Such insurance as is afforded by the General Liability policy is Primary Insurance and no other insurance of the
additional insured will be called upon to contribute to a loss as required by written contract.
CG 20 10 11 85 Copyright, Insurance Services Office, Inc. 1984 Page 1 of 1 ❑
ROYAL SURPLUS LINES INSURANCE COMPANY
Named Insured. ATLAS-ALLIED INC. Endorsement No:
Policy KZB518549 Effective Date. 11-1-01
COMMERCIAL GENERAL LIABILITY
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
OWNERS AND CONTRACTORS PROTECTIVE LIABILITY COVERAGE PART
SCHEDULE
Name of Person or Organization:
ANY PERSON OR ORGANIZATION AS REQUIRED BY WRITTEN CONTRACT
The TRANSFER OF RIGHTS OF RECOVERY AGAINST OTHER TO US Condition 8. (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 payment we make for injury or damage arising out of your ongoing operations or `your work done
under a written contract with that person or organization. This waiver applies only to the person or organization
shown in the Schedule above.
RSAI00I (I I/99),
CALIFORNIA ALL-PURPOSE ACKNOWLEDGMENT
IC
iq IG State of California 0I
is 1 ss. '1
'G County of C rain J '1
4 yl
4 On 51a9 ( OZ— , before me, -'Mnd( teki NUkrr.� , �
1a;
Date Name nd itle of Off' (e g Ja o Notary Public') ',
1e personally appeared C/1/t(-1 r bl
Iilame(s)of Sign ifs) '0
q�ersonally known to me 0,
it ❑ •• . • - . - •• ' • -- •ry 01
ii etri ferEa— 1
i 01
mt io FORTE to be the person('whose name(/is/ar� fI
G Cemmisicn# 1212058 z subscribed to the within instrument and 1
t r No.c y Fub!1c Ca!ifcrnia '' acknowledged to me that ly4/she/thy executed
f OtcngeCounty ;�
It � the same in hy�!/her/th0 authorized I
d —_. �i'z,� T� � ,: capacity(i and that by Fys/her/the(r
e signature(3on the instrument the person(y, or
e the entity upon behalf of which the person( 'i
acted, exec -. e 'nstrument. 0
1e WITNESS ■• hand and official eat. '1
4 ' e Si
I{ (a- Sc / [n 1
Pla Notary Seal Abo S,gnatu of Notary Public /rte 'I
OPTIONAL '1
lie 3
IcL Though the information below is not required by law, it may prove valuable to persons relying on the document
g and could prevent fraudulent removal and reattachment of this form to another document i
It Description of Attached cumentt " 9
% 1
4 Title or Type of Document `eii_f.t I5t kJP/J $1
%
iC Document Date 5` 2-4 `0L-, Number of Pages: 3 'i
it Signer(s) Other Than Named Above
1
it Capacity(ies) Claimed by Signer a
I% Signers Name RIGHTTHUIVBPRINT
I% ❑ Individual OFSIGFER 3
Iy Top of th lb here 'I
k ❑ Corporate Officer—Title(s): fi
4, ❑ Partner—❑ Limited ❑ General $1
ig ❑ Attorney in Fact e1
Ie ❑ Trustee
ie ❑ Guardian or Conservator
1, El Other a
SI
Signer Is Representing
I
R.C:crc.` C.'Otrtrcr.(,rc.CC.Y-c.Y�c.c:cr_- (,rcSCVevY=Vr-c.[:c,(`c.' (.rc,^evr�iX,<.'O()ec.(`trt,`m(.`et,�%c)cc)cc.`a(,`c4_ - S.I,
01999 N No ary Assoc,atwn• 350 So PO Box 2402•Chs orth CA 91313-402•www nat,onalnotary o Prod No 5907 Retook Call Toll Ft -60P676 6827
JUN-07-2002 ti• 1 Ca I H E IN P ST 71- 4 ,i 14.E H 4.1
RECEIVED
STATE P.O. BOX 420807 SAN FRANCISCO,CA 94142.0807 JUN 7 2002
CO IJIP EN'S A.1 ON
rNsu9A'NcE COSTAMESA:SM
FUND CERTIFICATE O F WORKERS' COMPENSATION INSURANCE
JUNE -5, 2002 PoucyNurasen• 519-01 UNIT 0000072
CERnHCATE EXPIRES. 11-1-02
COStA MESA SANITARY DISTRICT
CLERK GE THE bJSTRIGT'
FO BOX 1200
COSTA MESA CA 92880-1200 JOB: PROJECT #1112100-161
WATER SERVICES FOR SEWER
L PUMP STATION
. .1 .t, S l 7.f: may° i;r}Y
This is'to car4,1 tha[vv€have issCred a Validn/+orhers Compeasatlon insure ;e;tor ty it e totm approved by the California
Insurance Commissioner to the employer named below for the policy period indicated. _
T
•s colic;is not subject to cancellation by the Fund except upon ten days advar ce writle: notica tr tha emp Dyer.
We will aso give you TEN days'advance notice should this policy be canecl,ed prior to its normal expiration.
This ceftifidete.ot•fnsuiance is not an insurance policy and does rot amend, extend or•alter the anetzge afforded by the
policies fisted herein. No:t1tl' taridina any requirement, lean, or conditon Q.` a-,y contract or other document with
respect tdi which this certificate of insurance may'he 1SSUed or may pertain. the Insurance afforded by-the oolcies
descnoed'herein is subject to all the terms ecluslons and conditions of such policies.
katc-1
ALI-IicnizeD'ntYPEBE, TATIVE wRESaDAN
'th SI.YER"S LIABILITY LIMIT INCLUDING DEFENSE COST". 21,000 000 P,ER OCOJRRE NCE
ENDORSEMENT #2570 ENTITLED•WAIVER OF SUBROGATION EFFECTIVE
06/05/02 IS ATTACHED TO AND FORMS A PART OF THIS FOLICY
THIRD PARTY NAME COSTA MESA SANITARY DISTRICT
LYE,., {r`,�•. ;0..ik� v":eSr,=1;y '641' :u" ar j1±7-1a,t'`•r"'= t a . ..�
>ri--- ° ':?'?.1: ' '.Y+ iT %' ''1`,., :v `y 'Ri:t- t'S. �'t. :>i. J • :
EMPLOYER
1
MIAs-ALP En INC
1210 N LAS'SRISAS
AMIAHEIM CA 92806
.tS
TOTAL P 01