Insurance - White Nelson Diehl Evans LLP - 2013-01-02 RECEIVED
FEB•
0t2013.
AC�RDATE(/2/O )
. CERTIFICATE OF LIABILITY INSUI�A�NIC�FA,�iiAfttUSIRICI
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS.NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS
S 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), AUTHORIZED
REPRESENTATIVE OR PRODUCER,AND:THE CERTIFICATE HOLDER. . __ _ ___.__. . _
IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies) must be endorsed.'If._SUBROGATION IS'•W AIVED,subject_to_
the terms and conditions of the policy;certain policies•mayrequire an endorsement..A statement.on th.is,:certificate does not confer rights to tlie'
certificate'holder in•lieu of such.-endorsement(s).
PRODUCER'•i:?••Y -7-•;• -1.• ••. --.' i CONTACT STEVE. SCHNEIDER:;,-, . . ._._ - ------ ;-c. --
SILVER CREEK INSURANCE"AGENCY PHONE 714;838-0 6 9 3 A3 8:=94'3.8
IA/C.No.Ext): F
(A/X,No): 714=8
17742 IRVINE BLVD SUITE 203 E-MAIL STEVE @SILVERCREEKAGENCY.COM-_ "•-
ADDRESS: 1i.
INSURER(S)AFFORDING COVERAGE NAICYt .
TUSTIN CA 92780 INSURER A:HARTFORD CASUALTY INS. CO.
INSURED INSURERS:HARTFORD UNDERWRITERS INS. CO.
WHITE NELSON DIEHL EVANS LLP INSURERC:
2875 MICHELLE, SUITE 300 INSURERD:
IRVINE, CA. 92606 INSURERE:
INSURER F:
COVERAGES CERTIFICATE NUMBER: 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 ADDL SUER POLICY EFF POLICY EXP
LTR TYPE OF INSURANCE INSR S Y
WV R POLICY NUMBER ,�MM/DD/YYYYUMM/DD//YYYYL LIMITS
GENERAL LIABILITY EACH OCCURRENCE $ 1000000.
72SBAKZ9101 1/1/13 1/1/14 DAMAGE TO RENTED _
I COMMERCIAL GENERAL LIABILITY PREMISES(Ea occurrence) $ 300000
CLAIMS-MADE ✓ OCCUR .. MED EXP(Any one person) $ 10000
A X PERSONALB•ADV INJURY $, - 1000000
. - '- ,I ...' -;:,GE NERAL AGGREGATE:. $-; ....,:2.0'00000
..:GEN''L AGGREGATE LIMIT APPLIES PER: • : t E. :I...: PRODUCTS-COMP/OP AGG $ -2'0000-00
r .. ,...__
' POLICY. JECT LOC• ...••.
_ ANY AUTO ABILITY 72SBAKZ9101 1/1/13 -- 1/1/14 EaaaccdentSINGLE LIMIT t 1000000
•• AUTOMOBILE LIABILITY - - . . , .. .. - .,.- .... ._ '' _
•- -• BODILY INJURY'(Perperson) $ .•
A ALL OWNED .SCHEDULED X - .. BODILY INJURY(Per accident) $
- AUTOS AUTOS _
NON-OWNED .. --__ ' PROPERTY DAMAGE .
HIRED AUTOS y AUTOS . - (Per accident) $
UMBRELLA LIAB — OCCUR 72SBAKZ91O1 1/1/13 1/1/14 EACH OCCURRENCE• $ 4000000.
A ✓ EXCESS LIAB CLAIMS-MADE •X AGGREGATE $ 4000000
DED ✓ RETENTION$ 10,000 $
AND EMPL EMPLOYERS' 72WECIX3258 6/1/12 6/1/13 TORY LIMITS OER ...$
AND EMPLOYERS'LIABILITY Y/N
ANY
B OFFICER/MEMBER EXCLUDED?PROPRIETOR/PARTNER/EXECUTIVE N/A - E.L.EACH ACCIDENT $ 1006000
(Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $ 1000000
If yes,describe under
DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 1000000
■
■
DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (Attach ACORD 101,Additional Remarks Schedule,if more space is required)
Those usual to the Insured's Operations. The District, its directors, officers, employees, agents and
volunteers are listed as additional insured per the business liability form SS0008 attached to this
policy. Coverage is primary and non-contributory per the business liability coverage form SS0008.
. Wavier. of subrogation applies per form WC990006. 30 day advanced notice of cancellation, 10 day notice
for non-payment cancellation.
CERTIFICATE HOLDER CANCELLATION . •
\ J SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
Costa Mesa Sanitary Dist±icb ' THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
\"a\1 ACCORDANCE WITI{J�H�POLICY PROVISIONS.
At`tn: Sherry Kallabe, Admin. Mgr. /�,� //
I ijd
8 W. 19th Street 1 r' AUTHORIZED REPRF6E�LT 'IVE
sta Mesa CA 92627
19 8-2010 ACORD CORPORATION. All rights reserved.
ACORD 25(2010/05) The ACORD name and logo are registers marks of ACORD
•
POLICY NUMBER: 72 SBA KZ9101
•
Sit
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
ADDITIONAL INSURED - PERSON-ORGANIZATION
CITY OF VISTA
200 CIVIC CENTER DR
VISTA CA 92084-6275
CITY OF RANCHO SANTA MARGARITA, ITS ELECTED AND APPOINTED BOARDS,
COMMISSIONS, OFFICERS, AGENTS, AND EMPLOYEES ARE AN ADDITIONAL
INSURED PER THE BUSINESS LIABILITY COVERAGE FORM SS0008
ATTACHED TO THIS POLICY.
CITY OF RANCHO SANTA MARGARITA
ATTN: CITY MANAGER
22112 EL PASEO
RANCHO SANTA MARGARITA, CA 92688
COSTA MESA SANITARY DISTRICT
628 W 19TH ST
COSTA MESA, CA 92627
•
•
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• Form IH 12 00 11 85 T SEQ.NO. 003 Printed in U.S.A..Page 001
Process Date: 01/30/13 Expiration Date: 01/01/14