Insurance - Golden Bell Products Inc. - 2015-09-23A� o'® CERTIFICATE OF LIABILITY INSURANCE
DATE(MMM0D15Y)
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.
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(les) must be endorsed. If SUBROGATION IS WAIVED, subject to
the terms and conditions of the policy, certain policies ma require an endorsement. A statement on this certificate does not confer rights to the
certificate holder in lieu of such endorsement(s).
PRODUCER
CONTACT
NAME:Jeanette Heinrich0
Van Beurden InE. Serv, Inc. - Xingsburg
PO Box 67 OCT 0' 12015
FAX
AIC No Ext: (559) 897-2975 AIC No: (559) 897-4070
E-MAIL
Xingsburg CA 93631 C;;iA MESASANu1;)n uiSiRl
ADDRESS:
EACH OCCURRENCE $ 1,000,000
INSURERS AFFORDING COVERAGE NAICk
INSURERA: Lloyd's of London 15792
INSURED (714) 630-3861
INSURER B:
Golden Bell Products, Inc.
10/25/2016
DAMAGE TU RENTED
PREMISES Ea occurrence $ 50,000
INSURER C
INSURER D:
P.O. Box 366
INSURER E:
Atwood CA 92811
INSURER F:
COVERAGES CERTIFICATE NUMBER: Cert ID 22479 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. NOTVATHSTANDING 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.
ILTR
TYPE OF INSURANCE
ADDL
Dim
UBR
3M
POLICY NUMBER
POLICY EFF
MMIDD/YYYY
POLICY EXP
MM/DD/YYYY
LIMITS
A
X COMMERCIAL GENERAL LIABILITY
EACH OCCURRENCE $ 1,000,000
X CLAIMS -MADE OCCUR
151PGO57133
10/25/2015
10/25/2016
DAMAGE TU RENTED
PREMISES Ea occurrence $ 50,000
MED UP (My one person) $ 5,000
X Pest./Herb. Endt.
X BI/PD Dedt. 1,000
PERSONAL &ADV INJURY $ 1,000,000
GEN'L AGGREGATE LIMIT APPLIES PER:
GENERALAGGREGATE $ 2,000,000
X POLICY PRO- ❑ LOC
JECT
PRODUCTS - COMP/OP AGG $ 1,000,000
$
OTHER:
AUTOMOBILE LIABILITY
COMBINED SINGLE LIMIT $
Ea actldent
BODILY INJURY (Per person) $
ANY AUTO
ALL OWNED SCHEDULED
AUTOS AUTOS
BODILY INJURY (Per accident) $
PROPERTY DAMAGE $
Per accident
NON -OWNED
HIRED AUTOS AUTOS
UMBRELLA LIAB
OCCUR
EACH OCCURRENCE $
AGGREGATE $
EXCESS LIAB
CLAIMS -MADE
DED I I RETENTION$
$
WORKERS COMPENSATION
AND EMPLOYERS' LIABILITY YIN
PER OTH-
STATUTE ER
ANY PROPRIETORIPARTNERIEXECUTIVE
E.L. EACH ACCIDENT $
OFFICERIMEMBER EXCLUDED? F—]
MIA
(Mandatory In NH)
E.L. DISEASE - EA EMPLOYE $
If as, describe under
DESCRIPTION OF OPERATIONS below
E.L. DISEASE - POLICY LIMIT $
A
Tranait/Road Spill Endt. -
141PGO57138
10/25/2014
10/25/20151,000
Dedt. 1,000,000
A
Job Site Pollution
141PGO57138
10/25/2014
10/25/20152,500
Dedt. 50,000
DESCRIPTION OF OPERATIONS LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, maybe attached if more space is requlred)
Re: Manhole spraying for roaches at various city locations.
It is agreed that the Costa Mesa Sanitary District, its elected and appointed officials, officers,
agents, and employees are named as additional insureds as respects to General Liability per attached
additional insured form only when required by written contract.
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
Costa Mesa Sanitary District `O I1 /6 ACCORDANCE WITH THE POLICY PROVISIONS.
628 W. 19th Street 19t / AUTHORIZED REPRESENTATIVE
Costa Mesa CA 92627-0000 /�fllpr•L
l71QRR-9nlA A('nRII Cr1RPOPATION Ali rinhl� romn,nd
ACORD 25 (2014/01) The ACORD name and logo are registered marks of ACORD
POLICY NUMBER: 151PGO57133
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 Person or Organization:
BLANKET
AS REQUIRED BY WRITTEN CONTRACT
Location And Description of Completed Operations:
BLANKET
AS REQUIRED BY WRITTEN CONTRACT
Additional Premium:
NIA
(If no entry appears above, information required to complete this endorsement will be shown in the Declarations
as applicable to this endorsement.)
Section II — Who Is An Insured is amended to include as an insured the person or organization shown in the
Schedule, but only with respect to liability arising out of "your work" at the location designated and described in
the schedule of this endorsement performed for that insured and included in the "products -completed operations
hazard".
POLICY NUMBER: 151PG057133
COMMERCIAL GENERAL LIABILITY
CG 24 04 10 93
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
WAIVER OF TRANSFER OF RIGHTS OF RECOVERY
AGAINST OTHERS TO US
This endorsement modifies insurance provided under the following:
COMMERCIAL GENERAL LIABILITY COVERAGE PART
SCHEDULE
Name of Person or Organization:
BLANKET
AS REQUIRED BY WRITTEN CONTRACT
(If no entry appears above, information required to complete this endorsement will be shown in the
Declarations as applicable to this endorsement.)
The TRANSFER OF RIGHTS OF RECOVERY AGAINST OTHERS TO US Condition (Section IV —
COMMERCIAL GENERAL LIABILITY CONDITIONS) is amended by the addition of the following:
We waive any right of recovery we may have against the person or organization shown in the Schedule
above because of payments we make for injury or damage arising out of your ongoing operations or "your
work" done under a contract with that person or organization and included in the "products -completed
operations hazard". This waiver applies only to the person or organization shown in the Schedule above.
CG 24 04 10 93 Copyright, Insurance Services Office, Inc., 1992 Page 1
POLICY NUMBER: 151PGO57133 COMMERCIAL GENERAL LIABILITY
CG 20 10 10 93
NAME INSURED: Golden Bell Products, Inc.
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
ADDITIONAL INSURED - OWNERS, LESSEES OR
CONTRACTORS (FORM B)
This endorsement modifies insurance provided under the following:
COMMERCIAL GENERAL LIABILITY COVERAGE PART
SCHEDULE
Name of Person or Organization:
BLANKET
AS REQUIRED BY WRITTEN CONTRACT
Location of Covered Operations;
BLANKET
AS REQUIRED BY WRITTEN CONTRACT
(If no entry appears above, information required to complete this endorsement will be shown in the
Declarations as applicable to this endorsement.)
WHO IS AN INSURED (Section II) is amended to include as an insured the person or organization shown in
the Schedule, but only with respect to liability arising out of your ongoing operations performed for that
insured.
It is agreed such insurance as is afforded by this policy for the benefit of the additional insured(s) shown in the
endorsement, shall be primary insurance. Any other insurance maintained by the additional insured(s) shall be
excess and non-contributory not only as respect to any claim, loss or liability arising out of the operations of the
named insured, and only if such a claim, loss or liability is determined to be solely the negligence or responsibility
of the named insured.
CG 20 10 10 93 Copyright, Insurance Services Office, Inc., 1992 ❑