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Insurance - EBS Utilities Adjusting Inc. - 2011-12-28I.53WIIEtlUR ACORD,, CERTIFICATE OF LIABILITY INSURANCE DATE 1z /(MMIDD B /ao28 /20111YYI PRODUCER LIC 110628842 1 -949- 756 -4100 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Invensure Insurance Brokers, Inc. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR 17912 Mitchell South ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Irvine, CA 92614 INSURERS AFFORDING COVERAGE NAIC# INSURED BIDS Utilities Adjusting, Inc. INSURERA:WAUSAU UNDERWRITERS INS CO I�26042 INSURERB. LIBERTY INS CORP 42404 1320 R. Sixth St. INSURERC Corona, CA 92879 (INSURER D. LvVCMALPCJ 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 CONTRACTOR 01 HER 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. INSRI DD'L' POLICYEFFECTIVE I POLICY EXPIRATION LIMITS LTA POLICYNUMBER 111 A GENERALLIA WJ -Z91- 454286 -011 09128111 09/28/12 . EACH OCCURRENCE $1,000,000 % DAMAGETORENTEO COMMERCIAL GENERAL LIABILITY �: PREMISES (E mcurence) $300,000 CLAIMS MADE % � OCCUR I MEDFXP A 1 y ne person! $Excluded i PERSONAL& ADV INJURY I$ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GENT AGGREGATE LIMIT APPLIES PER PRODUCTS COMP /OPAGG $2,000,000 POLICY' % PRO- LOC _ A AUTOMOBILE LIABILITY ASJ -Z91- 454286 -021 09/28/11 09/28/12 COMBINED SINGLE LIMIT $1,000,000 %. ;ANYAUTO (Eaeaidenl) I ALLOWNED AUTOS BODILY INJURY $ I SCHEOULEDAUTOS (Perpelmn) % HIREDAUTOS ! BODILY INJURY $ X NON OWNED AUTOS (PerealdenQ - - PROPERTYDAMAGE IPeraceden0 $ ,GARAGE LIABILRY AUTOONLY- EAACCIDENT $ ANY AUTO ,OTHER THAN EAACC $ AUTOONLY: AGG $ B EXCESSNMBRELLA LIABILITY IITH7 -Z91- 454286 -041 ! 09/28/11 09/28/12 EACHOCCURRENCE $3,000,000 X OCCUR CLAIMS MADE AGGREGATE $3,000,000 $ DEDUCTIBLE ! $ S HETENTION $ 10,000 $ A WORKERS COMPENSATION AND WCJ -Z91- 454286 -031 09/28/11 09/28/12 WRY LIMIT DR X TORY LIMITS( ER EMPLOYERIETONPARI ANY PROPBIETOWPACLUDEDXEGUTIVE E.LEACHACCIDENT 1$1,000,000 - _ :OFFICEWMEMBEH EXCLUDED? % FIE. DISEASE EA EMPLOYEE $1,000.000 SPECIAL AL PROVISIONS below EL DISEASE POLICY NMIT $1,000,000 OTHER DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES / EXCLUSIONS ADDED BY ENDORSEMENT/ SPECIAL PROVISIONS Certificate holder is additional insured per attached endoreement forme #CG2033 07 04, CG2037 07 04. Primary A Non - contributory wording applies per attached andorsement form #LD 24 10 06 11. Project: Adjust Manholes to Grade Various locations - City of Costa Mesa l� ♦ n„cL�A nv.. „wL or non - payment. p ,I) SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION Costa Mafia Sanitary District ^ 11 V DATE THEREOF, THE ISSUING INSURER WILL d{ U00I M MAIL 30• DAYS WRITTEN J'PfTI V' NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, 628 W. 19th Street Xffmm XYYVYYXYXXXXXYYYYVXYYXYYAXXXX Costa Mesa, CA 92627 -2716 AUTHORIZED REPRESENTATIVE USA`_ ACORD 25 (2001/08) klopez © ACORD CORPORATION 19RR v u, O N e N J W PU.I .2 Policy Number YVJ -Z91- 454286 -011 Issued by Wausau Underwriters Insurance Company LL THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. LL 0 [1 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. rsmwzsxrz POLICY NUMBER: WT-Z91-454286-011 COMMERCIAL GENERAL LIABILITY CG 20 37 07 04 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. 3 ADDITIONAL INSURED -OWNERS, LESSEES OR f CONTRACTORS - COMPLETED OPERATIONS This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Name Of Additional Insured Person(s) Or Organization(s): Location And Description Of Completed Opera - tions Costa Mesa Sanitary District Adjust Manholes to Grade various locations - City of 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 u UFM 0 0 a 0 N z w