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Insurance - Gladwell Governmental Services - 2013-01-25 • i. ■ -----"Ii ' GLADW-1 OP ID: HE Ak� ® CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DDIYYYY) 01/25113 THIS CERTIFICATE IS ISSUED AS A MATTER O F INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES II)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 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). PRODUCER 909-435-0230 CONTACT Sawyer Cook Insurance PHONE FAX 909-798-7971 1200 California St.,Ste 260 LAIC,NP,at): (A/C,No): Redlands,CA 92374 a DRESS: Eric Sammons { INSURERS)AFFORDING COVERAGE 1 NAIC# INSURER A:Hartford Insurance Company 22357 INSURED Gladwell Governmental Services INSURER B;United States Liability Ins 25895 Diane Gladwell P.O.Box 62 INSURER C: Lake Arrowhead,CA 92352 INSURER D: INSURER E: ti _ INSURER F: I 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. ir—Tst1 fir,DM SUBR POLICY EFF POLICY EXP LTR I TYPE OF INSURANCE I1 INSR WVD POLICY NUMBER (MMIDDIYYYY) fMMIDO/YYYY) LIMITS GENERAL LIABILITY i I EACH OCCURRENCE 1$ 1,000,000 A X COMMERCIAL GENERAL LIABILITY X 72SBAFT4487 10/31/12 10/31/13 DAMAGE RENTED 1 ,1 000 000 PREMISES(Ea occurrence) $ CLAIMS-MADE X OCCUR ` MED EXP(Anyone person) S 10,000 PERSONAL IL ADV INJURY - 5 1,000,000 GENERAL AGGREGATE 5 2,000,000 • GEM_AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG j 5 2,000,000 I POLICY I I.7PR LOC I+$ AUTOMOBILE UASILITY 1 COMEINED SINGLE LIMIT LY INJURY $ BO X ANY AUTO 72UEGJR8553 10!31/12 10131/13 BODILY INJURY(Per person) 5 1,000,000 ALL AUTOS NED i1 SCHEDULED I BODILY INJURY(Per accident)1 ( 5 NON-OWNED PROPERTY DAMAGE HIRED AUTOS __!AUTOS ` (Per accident) 5 I i5 UMBRELLA(JAB I OCCUR (EACH OCCURRENCE $ EXCESS UAB CLAIMS-MADE. I AGGREGATE $ I DED 11 RETENTION 5 5 WORKERS COMPENSATION I - I WC STATU- 0TH- AND EMPLOYERS'UABILITY YIN I TORY LIMITS. ER ANY PROPRIETOR/PARTNER/EXECUTIVE [J 1 A I E.L.EACH ACCIDENT 5 OFFICERIMEMBER EXCLUDED? (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $ If yea,describe under i DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ B Errors&!missions SP1020955B 10/31/12 10/31/13 EA CLAIM 1,000,000 ANN AGG 2,000,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (Attach ACORD 101,Additional Remarks Schedule,if more space is required) *Except 10 day notice of non payment of premium. Costa Mesa Sanitary District is named as additional insured per attached TH12001185T, **This Certificate Supercedes Certificate dated 10/31/12** • CERTIFICATE HOLDER CANCELLATION 0.1/0/ - SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Costa Mesa Sanitary District ACCORDANCE WITH THE POLICY PROVISIONS. Attention; Joan Revak,Clerk `\19 of the Board AUTHORIZED REPRESENTATIVE • 1Co Coasta Mesa,, / . '� /J7 -, - Coasta Mesa,CA 92627 -�`/� �ji�j' �1L'/ ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD POLICY NUMBER: 72 SBA FT4487 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - PERSON-ORGANIZATION COSTA MESA SANITARY DISTRICT ATTENTION: JOAN REVAK, CLERK OF THE BOARD 628 W. 19TH ST. COSTA MESA, CA 92627 RE: CONSULTING FOR THE CITY ON RECORDS, MANAGEMENT INFORMATION. • • Form IH 12 0011 85 T SEQ.NO. 001 Printed in U.S.A. Page 003 (CONTINUED ON NEXT PAGE) Process Date: 08/15/12 Expiration Date: 10/31/13