The URL can be used to link to this page

Insurance - Ortiz Landscaping - 2016-07-13'� CERTIFICATE OF LIABILITY INSURANCE °"07/13=16 07LDER, 8 THIS CERTIFICATE IS ISSUED ASA 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 1S WAIVED, subject to the lanes and conditions of the Policy, cartaln policies may require an endorsement. A statement on this certificate does not confer rights to the Frexiny LaOo(9755368) LITR PxoxE 714-535-1054F' i w : 714318-5089 202 W Lincoln Ave Ste 0 may FF EHWL UMR9 OENER LUABINKRY INSURExe AFFORDNe COVERAGE NNCa Orange CA 92865-1057 CE E 1,090000 IN..A: Truck Insurance Excha a 21]09 INSURED INSURER a: Farman: Insurance Exchange 21652 ORTIZ. MICHAEL A INsuma c: Mid Century Insurance Company 21687 ORTIZ LANDSCAPING 10/22/2015 INSURER D: INJURY § 1,00.DDD 730 W ASTER PL INSURER E: SANTA ANA CA 92706 INaumR F: PRMUCTS-COMIRMPAGG $ 2,090,000 COVERAGES CERTIFICATF MUMRFR• Reulelnu 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. LITR TWE OF INSURANCE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN JIMI PoLICTMUMBER may FF POLICY E%P UMR9 OENER LUABINKRY CE E 1,090000 X `-"ERCIN-OENENLLLVBILITY CIAIMBfMDEOCCUR ore� E ,00,000 peleml $,000 MAMV A Y N 606240281 10/22/2015 10/22/2018 INJURY § 1,00.DDD GATE E 2,00.000 GERL AGOREGATE LIMIT APPLIES PER: PRMUCTS-COMIRMPAGG $ 2,090,000 X PCIICY PR0. L00 E AUTOMOBILE WSWTYB E0 a1 M BODILY INJURY(PerP ) § ANYAUTO UL Oa OWNED SCHEDULED AUTOS BODILY INJURY P ( era MMD E HIREDAUTOS NON-0VmFD AUTOS PR PERttOpMAGE PoreMeM § S UMBRELLA LM° OCCUR FACXOCCURflENCE § "COSW8 CWMS.NAOE gGGXEG2TE § DED I I RET .. § WORNERSCOMPENSATION AND EMPLOYERS' LMBILDT YIX ANYPROPAIETORRARTNEPR%ECUTNE OFFICER/MEMBER EXCWDEW ❑X/A fLwdata, In NN) UyRJe eYMer W OEBCRIPTpN OF OPEIipTONa below WC StRTU- OM E.L FACHALCIDEM E E.L OIBE09E-FA EMPLOYE f EA.OISEASE-POJCYLIMIT E MSCRNTONOFOPERARONSILOCAT S/Y ICLE9 (1mMA MDIDI,AddMon.R .m &SeMM,°moreepeubmWlmdI 730 W ASTER PL, SANTA ANA, CA 92706 GENERAL LIABILITY: THE DISTRICT, ITS DIRECTORS, OFFICIALS, OFFICERS, EMPLOYEES, AGENTS AND VOLUNTEERS SHALL BE COVERED AS ADDITINAL INSURED WITH RESPECT TO THE WORK OR OPERATIONS PERFORMED BY OR ON BEHALF OF THE APPLICANT, INCLUDING MATERIALS, PARTS OR EOUPMENT FURNISHED IN CONNECTION WITH SUCH WORK. ®1980-2010 ACRD COLORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE COSTA MESA SANITARY DISTRICT THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 628 W 19TH STREET ACCORDANCE WITH THE POLICY PROVISIONS. COSTA MESA CA 92627 AUMOPPA°REPRasENTArrvE ®1980-2010 ACRD COLORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD THIS ENDORSEMENT CHANGES THE PCJLICY. PLtAst HtAL) I I UAKW-ULLY. ADDITIONAL INSURED -- STATE OR POLITICAL SUBDIVISIONS - PERMITS RELATING TO PREMISES This endorsement modifies insurance provided under the following: BUSINESSOWNERS POLICY SCHEDULE* Slateor Political Subdivision_ TIHE COSTA MESA SANITARY SEE E0002 _ THE COSTA MESA SANITARY DISTRICT, IT'S ELECTED AND APPOINTED OFFICIALS, AGENTS, OFFICERS, VOLUNTEERS AND EMPLOYEES ARE ADDITIONAL INSUREDS The following is added to Paragraph C. WHO IS AN INSURED in the Businessowners Liability Coverage Form: 4. Any state or political subdivision shown in the Schedule is also an insured, subject to the follow- ing additional provision: This insurance applies only with respect to the following hazards for which the state or political subdivision has issued a permit in connection with premises you own, rent, or control and to which this insurance applies: a. The existence, maintenance, repair, construc- tion, erection, or removal of advertising signs, awnings, canopies, cellar entrances, coal holes, driveways, manholes, marquees, hois- taway openings, sidewalk vaults, street ban- ners, or decoration and similar exposures; b. The construction, erection, or removal of ele- vators; or c. The ownership, maintenance, or use of any. elevators covered by this insurance. * Information required to complete this Schedule, if not: shown on this endorsement, will be shown in the Decla- rations. BP 04 07 01 87 Copyright, Insurance Services Office, Inc., 1985 Page 1 of 1 0 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. Policy Number: 60624-02-91 POLICY CHANGES Effective Date of Change: 07/19/16 Change Endorsement No.: 004 Named Insured: ORTIZ, MICHAEL 730 WASTER PL SANTA ANA CA 92706-1166 The following item (s): Expiration Date: 10/22/16 Agent: 97-55-368 E4277 1st Edition is (are) changed to read {See Additional Page(s)}: The above amendments result in a change in the premium as follows: X I No Changes I I To Be Adjusted At Audit I Additional Premium I Return Premium Authorized Representative Signature: FARMERS INSURANCE 91-4277 ISTEOIOON 7-02 Indudes(WIghted Muleriol, Insurance Services OHire, Inc, w1h Is perminien. 14277101 PAGE 1 Of 2 E4277{Ol Insured's Name Insured's Mailing Address Policy Number Company Effective / Expiration Date Insured's Legal Status / Business of Insured Payment Plan Premium Determination X Additional Interested Parties Coverage Forms and Endorsements Limits / Exposures Deductibles Covered Property / Location Description Classification / Class Codes Rates Underlying Insurance is (are) changed to read {See Additional Page(s)}: The above amendments result in a change in the premium as follows: X I No Changes I I To Be Adjusted At Audit I Additional Premium I Return Premium Authorized Representative Signature: FARMERS INSURANCE 91-4277 ISTEOIOON 7-02 Indudes(WIghted Muleriol, Insurance Services OHire, Inc, w1h Is perminien. 14277101 PAGE 1 Of 2 E4277{Ol THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. Policy Number: 60624-02-91 POLICY CHANGES Effective Date of Change: 07/19/16 Change Endorsement No.: 004 Named Insured: ORTIZ, MICHAEL 730 WASTER PL SANTAANA CA 92706-1166 The following item(s): Expiration Date: 10/22/16 Agent: 97-55-368 E4277 Ist Edition is (are) changed to read {See Additional Page(s)}: The above amendments result in a change in the premium as follows: No Changes I I To Be Adjusted At Audit I Additional Premium Authorized Representative Signature: Return Premium FARMERS INSURANCE 914277 15TEOIPON 7-02 IndudesCopyrighted Mulerlul Innonce Semites Offia, Inc, with ds penremon. 14277101 PAGE I Of 2 14277 101 Insured's Name Insured's Mailing Address Policy Number Company Effective / Expiration Date Insured's Legal Status / Business of Insured Payment Plan Premium Determination X Additional Interested Parties Coverage Forms and Endorsements Limits / Exposures Deductibles Covered Property / Location Description Classification / Class Codes Rates Underlying Insurance is (are) changed to read {See Additional Page(s)}: The above amendments result in a change in the premium as follows: No Changes I I To Be Adjusted At Audit I Additional Premium Authorized Representative Signature: Return Premium FARMERS INSURANCE 914277 15TEOIPON 7-02 IndudesCopyrighted Mulerlul Innonce Semites Offia, Inc, with ds penremon. 14277101 PAGE I Of 2 14277 101 Attach to your policy with the same policy number shown on this endorsement. ENDORSEMENT Effective Date 07/19/16 60624-02-91 Policy Number of the Company designated in the Declarations ADDITIONAL INSURED-BP04070187 STATE/POLITICAL SUBDIVISION PERMITS -RELATED TO PREMISES THE COSTA MESA SANITARY DISTRICT, IT'S ELECTED AND APPOINTED OFFICIALS, AGENTS, OFFICERS, VOLUNTEERS AND EMPLOYEES ARE ADDITIONAL ISUREDS This endorsement is part of your policy. It supersedes and controls anything to the contrary. It is otherwise subject to all other terms of the policy. COUNTERSIGNED (Date) 91-0002 (E 0002) 1ST EDITION 3 8 iRRMF RS /1RSURAR<[ R