Project 187 - Insurance - Doty - 2011-10-27 Client#:6605 DOTYBROS
A CRD. CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DOIYVYY)
10/27/2011
PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
Edgewood Partners Ins.Center ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE CERTIFICATE DOES Lic#0629370 949.417-9175 Suzan RECEIVED I ALTER HOLDER.HE COVERAGE AFFORD DNBYTHE POLICIES BELOW.
19000 MacArthur Blvd. Penthse Fl.
Irvine,CA 92612 NQV 1 a 2011 INSURERS AFFORDING COVERAGE NAIC#
INSURED INSURER A Ins Co.of State of Penn �
Doty Bros. Equipment Co. COSTA hi1bA SANITARY DISTRICT INSURER B National Union Fire of PA
dba Doty Bros.Construction Co.
■
11232 East Firestone Blvd. INSURER C
INSURER D
Norwalk,CA 90650
INSURER E Sped
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 ADS I TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATION LIMITS
LTR NSRC DATE IMMIDDIYYI DATE(MM'DD/YY)
A GENERAL LIABILITY GL4871234 10/31/11 10/31/12 EACH OCCURRENCE $1,000,000
x COMMERCIAL GENERAL LIABILITY PREAISE S?E�cc EDnoel $100,000
CLAIMS MADE X OCCUR MED EXP Any o e person) $5 000
x BFPD/XCU PERSONAL&ADV INJURY $1,000,000
x Contractual Liabilit GENERAL AGGREGATE $2,000,000
GEN'L �I
AGGREGATE LIMIT APPLIES PER PRODUCTS COMP/OP AGG $2,000,000
7 POLICY I XI PELT 'LOC SIR $50,000
A AUTOMOBILE LIABILITY CA1707424 10/31/11 10/31/12 COMBINED SINGLE LIMIT $1,000,000
X ANY AUTO (E Went)
ALL OWNED AUTOS
BODILY INJURY $
SCHEDULED AUTOS (Per Pe nl
X HIRED AUTOS
BODILY INJURY $
X NON-OWNED AUTOS (Pe olden()
x Drive Other Car _
PROPERTY DAMAGE $
x Comp&Coll $1,000(2006& _ newer) (Pe cmenn
GARAGE LIABILITY AUTO ONLY EA ACCIDENT $
ANY AUTO OTHER THAN EA ACC $
AUTO ONLY AGG $
B EXCESS/UMBRELLA LIABILITY BE86308545 10/31/11 10/31/12 EACH OCCURRENCE $1,000,000
il OCCUR CLAIMS MADE AGGREGATE $1,000,000
DEDUCTIBLE $
X RETENTION $10,000 $
A WORKERS COMPENSATION AND WCO20635779 10/31/11 10/31/12 �WC STATU- OTH-
EMPLOYERS'LIABILITY z TORY LIMITS ER
ANY PROPRIETOR(PARTNERIEXECUTIVE EL EACH ACCIDENT $1,000,000
OFFICER/MEMBER EXCLUDED' EL DISEASE EA EMPLOYEE $1,000,000
If yes.de cribs under
SPECIAL PROVISIONS below EL DISEASE POLICY LIMIT $1,000,000
OTHER
DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES EXCLUSIONS ADDED BY ENDORSEMENT SPECIAL PROVISIONS
Evidence of insurance only.
CERTIFICATE HOLDER CANCELLATION 10 Days for Non-Payment
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION
Costa Mesa Sanitary District DATE THEREOF THE ISSUING INSURER WILL gQeWRRflMAIL 30_ DAYS WRITTEN
P.O. Box 120010-BE NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,ZIRR94KODQ7A1000QC$OKIXK
Costa Mesa,CA 92628 )MPAXKKaAapKxnKCOCRXIaBKKxXnOaxxxXaaXePlaKZe(ROECEMEXIODIRM000XXXx
KKIK3OMIXwwxxX
AUTHORIZED REPRF/GENTATIV�EV�yO,'���g/.
ACORD 25(2001/08)1 of 2 #5176668/M172942 (�{`{�//vrJ�a ` PAT2 0 ACORD CORPORATION 1988
IMPORTANT
It the certificate holder is an ADDITIONAL INSURED the policy(ies) must be endorsed. A statement
on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s).
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).
DISCLAIMER
The Certificate of Insurance on the reverse side of this form does not constitute a contract between
the issuing insurer(s), authorized representative or producer and the certificate holder nor does it
affirmatively or negatively amend, extend or alter the coverage afforded by the policies listed thereon.
ACORD 25-S(2001108) 2 of 2 #S176668/111172942