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Insurance-Heitkamp-2014-06-25A� ° CERTIFICATE OF LIABILITY INSURANCE INSIR LTR page 1 of 1 06/(25/2014 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 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 p01 icies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER Willis of New York, Inc. c/o 26 Century Blvd, P. 0. Box 305191 Nashville, TN 37230 -5191 CONTACT NAME: PHONE CN 877- 945 -7378 IF No: 888- 467 -2378 6 -M RIE SS: CertifiCateB@tV11118. COIIl INSURER(S)AFFORDING COVERAGE NAIC# RE C E I V ERA: Tokio Marine & Nichido Fire Insurance Co. 12904 -001 $ 11000,000 INSURED NeiCalle Inc. rr� INSURER B: INSURERC: 99 Callender Road JUL U 0 9 201 P.O. Box 730 ER D: ME-ER Watertown, CT 06795 COSTA MESA SANITARY O MED EXP(Anyone person) SUR ER E: PERSONAL& AOV INJURY INSURER F: COVERAGES CERTIFICATE NUMBER: 21743668 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. INSIR LTR TYPEOFINSURANCE DD WB POLICY NUMBER POLICYEF Y POLIEXY DD LIMITS • GENERAL LIABILITY Y CLL6403632 -06 7/1/2014 7/1/2015 EACH OCCURRENCE $ 11000,000 DAMAGE TO RENTED PREMISES Ea occurenca $ 11000,000 X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE OCCUR MED EXP(Anyone person) $ 10,000 PERSONAL& AOV INJURY $ 11000,000 GENERALAGGREGATE $ 2 000 000 GENIAGGREGATE LIMITAPPLIES PER X POLICY PRO- LOC IFCT PRODUCTS - COMP /OP AGG $ 2,000,000 • AUTOMOBILE LIABILITY Y CA 6402929 -05 7/1/2014 7/1/2015 COMBINED BINGLE LIMIT (Eaacadent $ 1, 000, 000 X BODILY INJURY(Per person) $ ANYAUTO ALLOWNED SCHEDULED AUTOS AUTOS BODILY INJURY(Peraccident) $ HIREDAUTOS NON -OWNED AUTOS ERTY OAMA Peraccident $ A X UMBRELLALIAB X OCCUR CU 6402931 -05 7/1/2014 7/1/2015 EACHOCCURRENCE $ 51000,000 AGGREGATE $ 5,000,000 EXCESS LIAB CLAIMS -MADE DED RETENTION$ $ TN/A A WORKERS COMPENSATION AND EMPLOYERS'LIABILITY YIN ANY PROPRIETOR/PARTNERIEXECUTIVE� CFFICER,W EMBER EXCLUDED? WC6402973 -05 7/1/2014 7/1/2015 X TRY ITS R E.L. EACH ACCIDENT $ 1,000,000 E.L. DISEASE - EA EMPLOYEE $ 1,000,000 Mandatmyin NH) fyes, describe ..de, E.L. DISEASE - POLICY LIMIT $ 1,000,000 DESCRIPTION OF OPERATIONS below DESCRI PION OF OPERATIONS/ LOCATIONS I VEHICLES (Attach Aeord 101, Additional Remarks Schedule, it more space is mquir") Division /Location: Pipe Lining Division Re: Prequalification Costa Mesa Sanitary District is included as an Additional Insured as respects to General Liability and Auto Liability as required by written contract. SHOULD ANY OF THE ABOVE DESCRIBED POUCI ES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Costa Mesa Sanitary Distric AUTHORI DR ESENTA Attn: Dyana Wick 628 W. 19th Street Costa Mesa, CA 92627 Coll:4449879 Tpl:1829255 Cert:21743668 © 88 -2010 ACORD CORPORATION. All rights reserved. ACORD 25 (2010/05) The ACORD name and logo are registered mark of ACORD THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - OWNERS, LESSEES OR CONTRACTORS - SCHEDULED PERSON OR ORGANIZATION This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Name Of Additional Insured Person(s) Or Organization(s): Location(s) Of Covered Operations DISTRICT and its employees and agents Division /Location: Pipe Lining Division Information required to complete this Schedule, if not shown above, will be shown in the Declarations. A. 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 ", "property damage' or "personal and advertising injury" caused, in whole or in part, by: 1. Your acts or omissions; or 2. The acts or omissions of those acting on your behalf; in the performance of your ongoing operations for the additional insured(s) at the location(s) designated above. B. With respect to the insurance afforded to these additional insureds, the following additional exclusions apply: This insurance does not apply to "bodily injury" or "property damage" occurring after: 1. All work, including materials, parts or equipment furnished in connection with such work, on the project (other than service, maintenance or repairs) to be performed by or on behalf of the additional insured(s) at the location of the covered operations has been completed; or 2. 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 subcontractor engaged in performing operations for a principal as a part of the same project. CG 2010 07 04 0 ISO Properties, Inc., 2004