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Insurance - Municipal Underground Services Inc. - 2013-04-19 ACORD TM CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD"3) THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HO&E[1 it ��t 0 CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHOPAI ^ ^ 2013 REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. //�� LAA��,I[TTnpyy (� IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must be endorsed. If SUBROGATION IS WAIVED,,�,4k VALA SANIIAR DISIgla the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer righ 1�I fil► J certificate holder in lieu of such endorsement(s). PRODUCER CONTACT NAME: Orion Risk Management Insurance Services, Inc. PHONE No,Ext): 951.736.9477 (AC,No):951.736.9478 Ca. Lic. #0D28764 E-MAIL ADDRESS: 2280 Wardlow Circle, Suite 250 PRODUCER 00001641 CUSTOMER ID#: Corona, CA 92880 INSURER(S)AFFORDING COVERAGE NAIC# INSURED INSURERA: Employers Mutual Casualty Co. Municipal Underground Services, Inc. INSURERB: 28511 Breckenridge Drive INSURER C: Laguna Niguel , CA 92677 INSURERD: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: 13-14 Auto REVISION NUMBER: THIS IS TO CERTIFY THAT 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.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR I TYPE OF INSURANCE ADDL SUBR (MMIDDIYYYY) (MM DDYIYYYY),EXP LTR 1 INSR WVD POLICY NUMBER LIMITS I GENERAL LIABILITY EACH OCCURRENCE I$ DAMAGE TO RENTED COMMERCIAL GENERAL LIABILITY PREMISES(Ea occurrence) 5 CLAIMS-MADE OCCUR MED EXP(Any one person) $ PERSONAL&ADV INJURY $ GENERAL AGGREGATE $ GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 0 POLICY f PRO - LOC $ I AUTOMOBILE LIABILITY JECT 4E43249 04/18/2013 04/18/2014 COMBINED SINGLE LIMIT $ (Ea accident) 1,000,000 X I ANY AUTO BODILY INJURY(Per person) $ ALL OWNED AUTOS BODILY INJURY(Per accident) $ A SCHEDULED AUTOS PROPERTY DAMAGE $ X HIRED AUTOS (Per accident) X NON-OWNED AUTOS $ UMBRELLA LIAB _ OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DEDUCTIBLE $ RETENTION- $- $ WORKERS COMPENSATION WC STATU- OTH- AND EMPLOYERS'LIABILITY Y/N TORY LIMITS ER- ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? N/A (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 1 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (Attach ACORD 101,Additional Remarks Schedule,if more space is required) Evidence of insurance CERTIFICATE HOLDER CANCELLATION ` ar SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Costa Mesa Sanitary District AUTHORIZED REPRESENTATIVE Y ltt q- 'r%; 628 W. 19th St. Costa Mesa, CA 92627 Victoria Codispoti, CISR/VAC ©1988-2009 ACORD CORPORATION. All rights reserved. ACORD 25(2009/09) The ACORD name and logo are registered marks of ACORD RECEIVED STATE COMPENSATION MAR 2 fj 2013 INSURANCE FU N D CusiA MO SANITARY DiSTRIcI IN REPLY REFER TO: MARCH 26, 2013 COSTA MESA SANITARY DISTRICT 628 W 19TH ST COSTA MESA CA 92627-2716 CERTIFICATE OF WORKERS' COMPENSATION INSURANCE CANCELLATION NOTICE RE: CERTIFICATE DATED NOVEMBER 5, 2012 THE WORKERS' COMPENSATION INSURANCE POLICY FOR THE EMPLOYER NAMED BELOW WILL BE CANCELLED EFFECTIVE MAY 1, 2013 AT 12:01 A.M. IF YOU HAVE ANY QUESTIONS REGARDING THIS NOTICE, PLEASE CONTACT THE EMPLOYER NAMED BELOW EMPLOYER: MUNICIPAL UNDERGROUND SERVICES, INC 28511 BRECKENRIDGE DR LAGUNA NIGUEL, CA 92677 POLICY 1714355-12 CUSTOMER SERVICE REPRESENTATIVE CUSTOMER SERVICE CENTER (877) 405-4545 5860 Owens Dr Pleasanton, CA 94588-3900 Mailing Address: P.O. Box 8192 Pleasanton, CA 94588-9682 SCIF 19102