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Insurance - EBS Utilities Adjusting Inc. - 2013-07-29 ACORDTM CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) 07/29/2013 PRODUCER LIC #0E28842 1-949-756-4100 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Invensure Insurance Brokers, Inc. R ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE EXEND OR HOLDER.17912 Mitchell South � ® AL ER THE HCOVERAGE A FORDED BY T EMPOLLIC ES BELOW. Irvine, CA 92614 JUL 3 0 2013 INSURERS AFFORDING COVERAGE • NAIC# INSURED INSURERA:WAUSAU UNDERWRITERS INS CO 26042 EBS Utilities Adjusting, Inc. LuaIAiVItSASANIiADYDISTRICT INSURER B:LIBERTY INS CORP 42404 1320 E. Sixth St. INSURER C: Corona, CA 92879 INSURER D: INSURER E: 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 ADD'L POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATION LIMITS LTR NSRD TYPE OF INSURANCE DATE(MM/DDIYY) DATE(MM/DDIYY) A GENERAL LIABILITY YVJ-Z91-454286-012 09/28/12 09/28/13 EACH OCCURRENCE $1,000,000 X COMMERCIAL GENERAL LIABILITY DAMAGE PREMISES(Eaoccurence) $300,000 CLAIMS MADE X OCCUR MED EXP(Any one person) $Excluded PERSONAL&ADVINJURY $1,000,000 GENERAL AGGREGATE $2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $2,000,000 POLICY X jECT LOC A AUTOMOBILE LIABILITY ASJ-Z91-454286-022 09/28/12 09/28/13 X COMBINED SINGLE LIMIT $1,000,000 ANY AUTO ALL OWNED AUTOS BODILY INJURY SCHEDULED AUTOS (Per person) X HIRED AUTOS BODILY INJURY X NON-OWNED AUTOS (Per accident) PROPERTY DAMAGE (Per accident) GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $ ANY AUTO OTHER THAN EA ACC $ AUTO ONLY: AGG $ B EXCESS/UMBRELLA LIABILITY TH7-Z91-454286-042 09/28/12 09/28/13 EACH OCCURRENCE _ $3,000,000 X OCCUR CLAIMS MADE AGGREGATE $3,000,000 ' DEDUCTIBLE $ X RETENTION $ 10,000 $ • A WORKERS COMPENSATION AND WCJ-Z91-454286-032 09/28/12 09/28/13 X TORVLAMITS OER EMPLOYERS'LIABILITY E.L.EACH ACCIDENT $1,000,000 ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? X E.L.DISEASE-EA EMPLOYEE $1,000,000 If yes,describe under SPECIAL PROVISIONS below E.L.DISEASE-POLICY LIMIT $1,000,000 OTHER DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS Certificate holder is additional insured per attached endorsement forms #CG2033 07 04, CG2037 07 04. Primary & Non-contributory wording applies per attached endorsement form #LD 24 10 06 11. Costa Mesa Sanitary District is additional insured. Project: Manhole Raising/Concrete Repair Project, Various Locations, Costa Mesa CERTIFICATE HOLDER CANCELLATION*except 10 days notice for non-payment. SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION Costa Mesa Sanitary District 1 \") DATE THEREOF,THE ISSUING INSURER WILL L A V5 MAIL 30* DAYS WRITTEN in/ /}� NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, X�GtTall(14Yf (nCII E X 628 W. 19th Street \"J ffi liffiXigattataigfiX XCAMMUg xXOUPW /CKMISKX X( EIMMEKX XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX Costa Mesa, CA 92627-2716 - AUTHORIZED REPRESENTATIVE USA ACORD 25(2001/08)klopez ©ACORD CORPORATION 1988 34948180 IMPORTANT If 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(2001/08) Policy Number YVJ-Z91-454286-012 Issued by Wausau Underwriters Insurance Company THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. PRIMARY AND NON-CONTRIBUTORY—SCHEDULED ADDITIONAL INSURED This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE PART LIQUOR LIABILITY COVERAGE PART Schedule Person or Organization: As required by written contract or agreement entered into prior to loss If you are obligated under a written agreement to provide liability insurance on a primary, excess, contingent, or any other basis for any person or organization shown in the Schedule that is an additional insured on this policy, this policy will apply solely on the basis required by such written agreement If the applicable written agreement does not specify on what basis the liability insurance will apply, this insurance shall be excess over any other valid and collectible insurance available to the additional insured,whether such insurance is on an excess, contingent or primary basis. Condition 4 Other Insurance of Section IV is revised accordingly. LD 24 10 06 11 ©2011 Liberty Mutual Group of Companies.All rights reserved. Page 1 of 1 Includes copyrighted material of Insurance Services Office, Inc.,with its permission. EBS Utilities Adjusting, Inc. COMMERCIAL GENERAL LIABILITY YVJ-Z91-454286-012 CG 20 33 07 04 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - OWNERS, LESSEES OR CONTRACTORS - AUTOMATIC STATUS WHEN REQUIRED IN CONSTRUCTION AGREEMENT WITH YOU This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART A. Section II — Who Is An Insured is amended to B. With respect to the insurance afforded to these include as an additional insured any person or or- additional insureds, the following additional exclu- ganization for whom you are performing operations sions apply: when you and such person or organization have This insurance does not apply to: agreed in writing in a contract or agreement that such person or organization be added as an addi- 1. "Bodily injury", "property damage" or "personal tional insured on your policy. Such person or or- and advertising injury" arising out of the render- ganization is an additional insured only with re- ing of, or the failure to render, any professional spect to liability for "bodily injury", "property architectural, engineering or surveying ser- damage" or "personal and advertising injury' vices, including: caused, in whole or in part, by: a. The preparing, approving, or failing to pre- 1. Your acts or omissions; or pare or approve, maps, shop drawings, opinions, reports, surveys, field orders, 2. The acts or omissions of those acting on your change orders or drawings and specifica- behalf; tons; or in the performance of your ongoing operations for b. Supervisory, the additional insured. R ry, inspection, architectural or engineering activities. A person's or organization's status as an additional 2. "Bodily injury" or "property damage" occurring insured under this endorsement ends when your after: operations for that additional insured are com- pleted. a. All work, including materials, parts or equipment furnished in connection with such work, on the project (other than ser- vice, maintenance or repairs) to be per- formed by or on behalf of the additional in- sured(s) at the location of the covered operations has been completed; or b. That portion of"your work" out of which the injury or damage arises has been put to its intended use by any person or organization other than another contractor or subcontrac- tor engaged in performing operations for a principal as a part of the same project. CG 20 33 07 04 ©ISO Properties, Inc., 2004 Page 1 of 1 POLICY NUMBER: YVJ-Z91-454286-012 COMMERCIAL GENERAL LIABILITY CG 20 37 07 04 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - OWNERS, LESSEES OR CONTRACTORS - COMPLETED OPERATIONS This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Name Of Additional Insured Person(s) Location And Description Of Completed Opera- Or Organization(s): tions Costa Mesa Sanitary District Manhole Raising/Concrete Repair Project, Various Locations, Costa Mesa 628 W. 19th Street Costa Mesa CA 92627-2716 Information required to complete this Schedule, if not shown above, will be shown in the Declarations. Section II — Who Is An Insured is amended to include as an additional insured the person(s) or organization(s) shown in the Schedule, but only with respect to liability for "bodily injury" or "property damage" caused, in whole or in part, by "your work" at the location designated and described in the schedule of this endorsement performed for that additional insured and included in the "products- completed operations hazard". CG 20 37 07 04 ©ISO Properties, Inc., 2004 Page 1 of 1 ❑