Insurance - Mike Kilbride - 2015-11-10q�aRn° CERTIFICATE OF LIABILITY INSURANCE I DATE ,MwDDn ,
11/10/2015
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 may require an endorsement. A statement on this certificate does not confer rights to the
certificate holder in lieu of such endorsement(s).
PRODUCER Phone: (760) 837-3626 Fax. (760) 837-3898 CONTACT M. L . Adams Insurance Services
M. L. ADAMS INSURANCE SERVICES NAME: _
42-280 BEACON HILL, SUITE D-7 lac N ,EA: (760) 837-3626 - -_ _ NC FAX (760) 837-3898
(A/C, Nog. _
E-MAIL www.mladamsins.com
PALM DESERT CA 92211-5168 ADDRESS:
INSURED
MIKE KILBRIDE, LTD.
COAST WATER AND POWER
P.O. BOX 3341
NEWPORT BEACH CA 92659
0609232
R E -C F
NOV 16 -2M-
COSTA MESA SANITARY DISTRICT
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,
INSURER(SI AFFORDING COVERAGE NAICk
INSURER
INSURER B
Gemini Insurance CO
_.
State Compensation Insurance Fund
INSURERG :
Great American E & S Insurance Co
INSURER O'.
POLICY EFF
wsuRERE
LIMITS
INSURERF
X
COVERAGES
CERTIFICATE NUMBER: 21994
VOGPOO1519
REVISION N1IMRFR-
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
yTR_____
A
TYPE OF INSURANCE
ADDL
INSD._wyD
SUER
POLICY NUMBERIMMmorcrrYl
POLICY EFF
POLICY EXP
IMm(DD�
LIMITS
X
COMMERCIAL GENERAL LIABILITY
VOGPOO1519
10130/15
10130/16
EACH OCCURRENCE
$ 1,000,000
CLAIMS -MADE X OCCUR
--
DAMAGE SisoN m
PREMISES (Ee occurence)
$ 300,000
MED. EXP (Any one person)
$ 10,000
$ 1,000,000
PERSONAL &ADV INJURY
GENT
AGGREGATE LIMIT APPLIES PER:
PRO-
POLICYF—,�JECT 1:1 LOC
GENERALAGGREGATE
PRODUCTS - COMP/OP AGO
$ 2,000,000
$ 210661
OTHER:.
AUTOMOBILE
-
LIABILITY
a COMBINEDSINGLELIMIT
(Ea eccNenO
(Ea
$
ANY AUTO
ALL OAUTOS
AUUTOSS —..—
BODILY INJURY (Per person)
$
BODILY
BODILY INJURY(Per accident)
$
HIRED AUTOS NON -OWNED
AUTOS
PROPERTYDAMAGE —
(ce'.ccitlen0
----"---_--
$
C
UMBRELLA MB
X
OCCUR
XS3306768
10130115
10/30/16 —EAGAILOCCAURRENCE
$ 2,006,000
EXCESS LIAR
CLAIMS -MADE
AGGREGATE
$ 2,000,006
DED RETENTION $
$
B
WORKERS COMPENSATION
AND EMPLOYERS' LIABILITY
ANY PROPRIETORIPARTNER/E%ECUTrvE YIN
MandatoryOFFICEWMEMBER EXCLUDED?
In FIT)
NIA
9087110-15
10101/15
16161/16
X STATUTE TERN
1,666,666
EL EACH ACCIDENT
$ 1,666,666
E.L. DISEASE -EA EMPLOYEE $ INCLUDED
fyes,d
DES b antler
OESCRIPTIONOFOPERATIONS below
�
E L DISEASE -POLICY LIMIT I $ INCLUDED
DESCRIPTION OF OPERATIONS I LOCATIONS /VEHICLES (ACORD 701, Additional Remarks Schedule, maybe b attached if more space is required)
TEN DAY NOTICE OF CANCELLATION WILL BE GIVEN FOR NON PAYMENT OF PREMIUM.
CERTIFICATE HOLDER IS NAMED AS ADDITIONAL INSURED PER FORM CG 20 10 10 01 ATTACHED.
I CRI Ir'MA IC MULUMM UAINUCLLAI IVN
COSTA MESA SANITATION DISTRICT AND ITS OFFICERS, AGENTS
AND EMPLOYEES
628 W. 19TH STREET
COSTA MESA CA 92627-2718
Attention: ll//
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
Michael L. (Mike) Adams
the ACORD name and logo are registered marks of ACORD
Policy Number: VOGP001519
Insured Name:Mike Kilbride Ltd.
Number: 11
CG 201010 01
Effective Date: 10/30/2015
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
PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE PART
SCHEDULE
Name of Person Or Organization:
For Non -Residential and Non -Mixed use projects only. Any person or organization whenyou and such person or
organization have agreed in writing in acontract, prior to an occurrence that causes "bodily injury", "property
damage" :or "personal and advertising injury",. that such person or organization he added asan additional insured on.
your policy.;:For Non -Residential and Non -Mixed use projects only. All locations for which you and the additional
ensured have agreed in writing in a contract prior to an occurrence that causes "bodily injury', "property damage" or
"personal.and advertising injury".
(If no entry appears above, information required to complete this endorsement will be shown in
the Declarations as applicable to this endorsement.)
A. 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 ongoing operations
performed for that insured.
B, With respect to the insurance afforded to these additional insureds, the following exclusion is
added:
2. Exclusions
This insurance does not apply to "bodily injury" or "property damage" occurring after;
(1) .411 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 site 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 201010 01 Page 1 of 1