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Insurance - EBS Utilities Adjusting Inc. - 2015-10-27P52LW1MMn ACORD� CERTIFICATE OF LIABILITY INSURANCE °"T/27/2015 10/a7/zols PRODUCER LIC #OB28842 1-949-756-4100 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Invensurs Insurance Brokers, Inc. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR 17991 Cowan ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. EACHOOCURRENCE Irvine, CA 92614 Bob Parent INSURERS AFFORDING COVERAGE NAIC# _ _ _ _ _ _ _ INSURED INSURERA: LIBERTY NOT PIRG INS COQ 23035 EBS General Engineering, Inc.---- -- X $5,000 Deductible INSURER E:LIBERTY INS CORP / 1320 E. Sixth St. #100 j�142404 GENERALAGGREGATE - INSURERC: Corona, CA 92879 INSURERD: _ $2, 000, ODO 0D0__ 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. #NSR ADD'0 ___ POUCYNUMBER DATE(POLICYMWDiYVE POLICYEXPIBATON MMRS A ''. GENERALLMBILDY TB2-Z91-454286-015 09/28/15 09/28/16 EACHOOCURRENCE X'. COMMERCIAL GENERAL LIABILItt UAMAGETOHENTED-._ PREMISESIEa mcwrenr� _$1,000,000 -- --- $100,000 CLAIMSMADE X OCCUR MEDEXP(AnywN'.iU $Excluded X $5,000 Deductible _ PERSONAL& ADV INJURY_ $ 1,000,000 -__- I GENERALAGGREGATE - $ 2,000,000- - GENLAGGREGATELIMIT APPDESPER: PRODUCTS-COMP/OPAGG $2, 000, ODO 0D0__ -X'RO P - POLICY POLICY LOC A AUTOMOBILE LIABILITY A92-891-454286-025 09/28/15 09/28/16 GOMBINEDSINGLE LIMIT X (Eaecciden0 $1,000,000 ANYAUTO ALLOWNEDAUTOS BODILYINJURY $ SCHEDULEDAUTOS (P.w.n) X HIREDAUTOS BODILYINJURY X NON-OWNEDAUTOS (Per axXwni $ PROPERTY DAMAGE �$ GARAGELIABILITY AUTO ONLY -EA ACCIDENT S ANYAUTO OTHERTHAN EAACC $ AUTOONLY: AGO $ B EXCESwMSRELLAUABIUTY TE7-Z91-454286-045 09/28/15 09/28/16 E_ACHOCCUR_RENCE $4,000,000 X OCCUR CLAIMS MADE AGGREGATE ig 4,000,000 DEDUCTIBLE $ X RETENTION $ 10,000 i$ A WORKERS COMPENSATKNIAND WC2-Z91-454286-035 09/28/15 09/28/16 X WCSTATU- DTH- _ - TGHY LIMITS _ ER EMPLOYERS-UMBILrtY NT E.L.EACH ACCIDENT $1,000,000 ANY PROPRNTOFPARTNERVEXECUUVE -- —--- - - - OFFICERaIEMBER EXCLUDED? X E.L. DISEASE -EA EMPLOYEE $1,000,000 Ilyes.dew,,ww r SPEC IALPROVISIONSM. E.L. DISEASE -POLICY LIMIT $1,000,000 OTHER DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT/ SPECNL PROVISIONS --Additional insured form CO2037 04 13 & CG2033 04 13 and blanket WC waiver of subrogation # WC040306 4/84 are attached Primary wording LC 24 20 02 13 applies Par attached. ::Costa Mesa Sanitary District, its directors, officials, officers, employees, agents and volunteers are additional insureds. Project: Sewer Manhole Surface Repair Program - Phase II ; Project # 311 EBS Job #15110 a Mesa Sanitary District W. 19th St. a Mae, CA 92627 USA IRD 25 (2001/08) kloper 45328421 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE BISUING INSURER WILL aNkFAW MAIL 30' DAYS WHMEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, P.Vl— OACORD CORPORATION 1988 7 fi P52E 2M2 n Q 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) 9 W a VSlfi1X1}%W2 Policy No. TB2-Zg1-454286-015 COMMERCIAL GENERAL LIABILITY CG 20 33 0413 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 include as an additional insured any person or organization for whom you are performing operations when you and such person or organization have agreed in writing in a contract or agreement that such person or organization be added as an additional insured on your policy. Such person or organization is an additional insured only with respect to liability for 'badly 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. However, the insurance afforded to such additional insured: 1. Only applies to the extent permitted by law; and 2. Will not be broader than that which you are required by the contract or agreement to provide for such additional insured. A person's or organization's status as an additional insured under this endorsement ends when your operations for that additional insured are completed. CG 20 33 0413 B. With respect to the insurance afforded to these additional insureds, the following additional exclusions apply: This insurance does not apply to: 1. 'Bodily injury'. "property damage" or 'personal and advertising injury" arising out of the rendering of, or the failure to render, any professional architectural, engineering or surveying services, including: a. The preparing, approving, or failing to prepare or approve. maps, shop drawings, opinions, reports, surveys, field orders, change orders or drawings and specifications; or b. Supervisory, inspection, archtectural or engineering activities. This exclusion applies even it the claims against any insured allege negligence or other wrongdoing in the supervision, hiring, employment, training or monitoring of others by that insured. if the occurrence' which caused the "bodily injury" or property damage", or the offense which caused the "personal and advertising injury", involved the rendering of or the failure to render any professional architectural, engineering or surveying services. C Insurance Services Office, Inc., 2012 Page 1 of 2 2. "Bodily injury" or 'property damage' occurring after. a. 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 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 subcontractor engaged in performing operations for a principal as a part of the same project. Page 2 of 2 C, With respect to the insurance afforded to these additional insureds, the following is added to Section III — Liml to Of Insurance: The most we will pay on behalf of the additional insured is the amount of insurance; 1. Required by the contract or agreement you have entered into with the additional insured; or 2. Available under the applicable Limits of Insurance shown in the Declarations; whichever is less. This endorsement shall not increase the applicable Limits of Insurance shown in the Declarations. C Insurance Services Office, Inc., 2012 CG 20 33 0413 p<xa.rzwx,z POLICY NUMBER: TB2-Z91-454286-015 COMMERCIAL GENERAL LIABILITY CG 20 37 0413 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 PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE PART 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" 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". However. 1. The insurance afforded to such additional insured only applies to the extent permitted by law; and Z If coverage provided to the additional insured is required by a contract or agreement, the insurance afforded to such additional insured will not be broader than that which you are required by the contract or agreement to provide for such additional insured. Name Of Additional Insured Person(s) Or Organization(s): Blanket where required by written contract executed prior to a loss or occurrence. B. With respect to the insurance afforded to these additional insureds, the following is added to Section III —Limits Of Insurance: If coverage provided to the additional insured is required by a contract or agreement, the most we will pay on behalf of the additional insured is the amount of insurance: SCHEDULE 1. Required by the contract or agreement; or 2. Available under the applicable Limits of Insurance shown in the Declarations; whichever is less. This endorsement shall not increase the applicable Limits of Insurance shown in the Declarations. Location And Description Of Completed Operations Any Information required to complete this Schedule, if not shown above, will be shown in the Declarations. CG 20 37 0413 ® Insurance Services Office, Inc., 2012 Page 1 of 1 Policy Number TB2-Z91-454286-015 Issued by Liberty Mutual Fire Ins. Co. THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. OTHER INSURANCE AMENDMENT—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: All persons with whom you have a written agreement to include them as Additional Insured, which is signed in advance of the "occurrence" or offense for which the Additional Insured seeks coverage. 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 of this endorsement that qualifies as an additional insured on this policy, this policy will apply solely on the basis required by such written agreement and Paragraph 4. Other Insurance of Section IV - Conditions will not apply. If the applicable written agreement does not specify on what basis the liability insurance will apply, the provisions of Paragraph 4. Other Insurance of Section IV - Conditions will govern. However, this insurance is excess over any other insurance available to the additional insured for which it is also covered as an additional insured by attachment of an endorsement to another policy providing coverage for the same "occurrence", claim or "suit". LC 24 20 02 13 0 2013 Liberty Mutual Insurance. All rights reserved. Page 1 of 1 Includes copyrighted material of Insurance Services Office, Inc., with its permission. raxnrozwxv W WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT CALIFORNIA We have the right to recover our payments from anyone liable for an injury covered by this policy. We wail not enforce our right against the person or organ¢abon named in the Schedule. (This agreement applies only to the extent that you perform work under a written contract that requires you to obtain this agreementfrom us.) 7 w You must maintain payroll records accurately segregating the remuneration of your employees while engaged in the work described in the Schedule. The additional premum for this endorsement shall be 2.0% of the California workers' compensation premium otherwise due on such remuneration. Schedule Person or Organization Job Desc_' 'on Where required by contract or written agreement prior to loss and allowed by law, Issued by Liberty Mutual Fire Insurance Company For attachment to Policy No.WC2-Z91-454286-035Effective Date 9/28/15 Premium$ Issued to EBS General Engineering, Inc. WG 04 03 06 ED: 0411984 Page 1 of 1