Insurance - F.M. Thomas Air Conditioning - 2012-12-28FMTHOMA -01 PIMI
A°A
ls CERTIFICATE OF LIABILITY INSURANCE
O / Y)
12 /28/2012
THIS CERTIFICATE IS ISSUED AS A MATTER OF 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
RcLOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED
'RESENTATIVE 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 en t
PRODUCER - B 825 -4322
( j
CONTACT
NAME: Michelle PIIuso
Bowermaster & Associates
P.O. Box 6026 DEC 3 1 1012
10805 Holder Street - Suite 350
PHONE 774 - 733 -6208 FAX
No Eat : ac No): 714- 252 -8253
M
ADDRESS: mpiluso@bowermaster.com
INSURER(S) AFFORDING COVERAGE
NAIC #
Cypress, CA 90630 CU61A mtSA SOW DISRICI.
INSURER A: Golden Eagle Insurance Corporation
$ 1,000,00
PREMISES Ea olcwrrence
INSURED F. M. Thomas Air Conditioning, Inc. & Thomas &
INSURER B: Insurance Company of the West
$ 10,00
INSURERC: RSUI Indemnity Company
$ 1,000,00
Carolyn Feyka
231 Gemini Ave.
Brea, CA 92821
INSURER O:
$ 2,000,00
INSURER E:
PRODUCTS - COMP /OP AGG
INSURER F;
$
COVERAGES CERTIFICATE NUMBER: PFVLCInhl NI IMRFR-
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
TYPE OF INSURANCE
ADD
INSR
BR
MID
POLICY NUMBER
POLICYEFF
MM /DD/YYYY
MM /DD/YYYY
LIMITS
A
GENERAL LIABILITY
X COMMERCIAL GENERAL LIABILITY
CLAIMS -MADE lxl OCCUR
X
CBP8636340
411/2012
411/2013
EACH OCCURRENCE
$ 1,000,00
PREMISES Ea olcwrrence
$ 500,06
MED EXP (Any one person)
$ 10,00
PERSONAL & ADV INJURY
$ 1,000,00
GENERAL AGGREGATE
$ 2,000,00
GEN'LAGGREGATE LIMIT APPLIES PER:
X POLICY PRO LOC
PRODUCTS - COMP /OP AGG
$ 2,000,00
$
A
UTOMOBILE
X
LIABILITY
ANY AUTO
ALL OWNED SCHEDULED
AUTOS AUTOS
HIRED AUTOS X NON -OWNED
AUTOS
BA8636640
4/112012
41112013
OMBINEDISINGLE LIMIT
$ 1,000,00
BODILY INJURY (Per person)
$
BODILY INJURY Per accitlenl
$
X
PROPERTY DAMAGE
Per accident)
$
A
X
UMBRELLA LIAR
EXCESS LIAB
OCCUR
CLAIMS -MADE
CUB765526
411/2012
4/112013
EACH OCCURRENCE
$ 2,000,00
AGGREGATE
$ 2,000,00
OEO I X RETENTION$
$
B
WORKERS COMPENSATION
AND EMPLOYERS' LIABILITY V /N
ANY PROPRIETOR /PARTNER /EXECUTIVE
OFFICER /MEMBER EXCLUDED?
(Mandatory in NH)
If yes, describe under
DESCRIPTION OF OPERATIONS below
NIA
WSD500540402
1/112013
1/1/2014
X WC STA7U- OTH-
TORY LIMITS ER
E.L. EACH ACCIDENT
$ 1,000,00
E.L. DISEASE - EA EMPLOYEE
$ 1,000,00
E . DISEASE - POLICY LIMIT
$ 1,000,00
C
Commercial Umbrella
NHA230191
4/1/2012
41112013
Limit $2,000,00
DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required)
Costa Mesa Sanitary District is Additional Insured as respects General Liability per form GECG6020904.
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.
628 W. 19th Street \\'\N
Costa Mesa, CA 92627 -i AUTHORIZED REPRESENTATIVE
U 1988 -2010 ACORD CORPORATION. All rights reserved.
ACORD 25 (2010105) The ACORD name and logo are registered marks of ACORD