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Insurance - Manhole Adjusting 2017-01-09/e"i _ MANHADJ-01 BSHIELDS s)►coRO" CERTIFICATE OF LIABILITY INSURANCE DATE(MMMONYYY) '141 0110 912 01 7 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 have ADDITIONAL INSURED provisions or 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 License # OK07668 I u°rUACT Bonnie Shields BusbVtone Insurance Services, LLC 9201 Camino Media Suite 250 P.O.Box 22620 Bakersfield, CA 93311 INSURED Manhole Adjusting Inc. 9500 Beverly Road Pico Rivera, CA 90660-2135 rOOTrnrATC \e IIIIGeR. 665-9150�) INSURER(S) AFFORDING COVERAGE I NAIC_#_ A: Travelers Property Casualty Co of America ,25674 B:Travelere Casualty & Surety CID T C. _ D;- I E: F: RFVISIrTM MI IMRFR• 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. Costa Mesa Sanitary District '9$ 11 628 W. 19th St. r� INSR ADDL SUER POLICY EFF POLICY E%P LTR TYPE OFINSURANCE INSO WVD POLICY NUMBER MMIOD/YYYY MMMO LIMITS Costa Mesa, CA 92627 A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1'000'000 CLAIMS -MADE OCCUR X C04E966229-TCT-16 04130/2016 04/30/2017 DAMAGE S TOoccurerce) _ $ 300,000 5'000 MED EXP (Any one person) $ 1,000'000 PERSONAL B ADV INJURY $ 2,000,000 GE_N'L AGGREGATE LIMIT APPLIES PER: _ GENERAL AGGREGATE_ 5_ POLICY X JECT LOC PRODUCTS -COMP/OP AGG _ S 2,000,000 Included OTHER: $ B COMBINED SINGLE LIMIT 1,000,000 AUTOMOBILE LIABILITY SEa accident__— __ _ 8 _ X ANY AUTO8104E97743A-TCT-16 0413012016 04/3012017 BODILY INJURY (Re r_perso�. $ OWNED _ SCHEDULED AUTOS ONLY AUTOS BODILY INJURY (Per acciden0_ $ ITED oT I PROPERTY DAMAGE ONLY AUTOS ONLY _TOaccitlenp _ $ with Comp & $1.000 Deductible X &I. X $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS MADE AGGREGATE $ DED RETENTION$ S A WORKERS COMPENSATION X PEROTRH- AND EMPLOYERS'LIAeILITY YIN UB4E860816-16 04130/2016 04/30/2017 1,000,000 ANY PROPRIETORIPARTNER/EXECUTIVE E.L. EACH ACCIDENT _ 5. OFFICER MENIg R EXCLUDED?NIA _ _ 1,000,000 (Mandatory In NFFI —, E.L. DISEASE -EA EMPLOYEY '$ It yes, desonbe untler 1,000,000 DESCRIPTION OF OR below E.L. DISEASE - POLICY LIMIT $ DESCRIPTION OF OPERATIONS I LOCATIONS l VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more seeace is required) Adjust and Surface Repair twenty five (25) Sewer Manholes, Project No. 311, Phase 3, MAI's Job No. MP17-14033 Costa Mesa Sanitary District along with their elected officials, officers, employees and agents are named as additional insured per attached endorsement. r FRTIFICATF Nnl nFR CANCELLATION ACORD 25 (2016103) - ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Costa Mesa Sanitary District '9$ 11 628 W. 19th St. r� AUTHORU:ED REPRESENTATIVE Costa Mesa, CA 92627 ACORD 25 (2016103) - ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD Policy No.: C04E966229-TCT-16 COMMERCIAL GENERAL LIABILITY THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY BLANKET ADDITIONAL INSURED (CONTRACTORS) This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART 1. WHO IS AN INSURED — (Section II) is amended to include any person or organization that you agree in a "written contract requiring insurance" to include as an additional insured on this Cover- age Part, but: a) Only with respect to liability for "bodily injury", "property damage" or "personal injury"; and b) If, and only to the extent that, the injury or damage is caused by acts or omissions of you or your subcontractor in the performance of "your work" to which the "written contract requiring insurance" applies. The person or organization does not qualify as an additional insured with respect to the independent acts or omissions of such person or organization. 2. The insurance provided to the additional insured by this endorsement is limited as follows: a) In the event that the Limits of Insurance of this Coverage Part shown in the Declarations exceed the limits of liability required by the "written contract requiring insurance", the in- surance provided to the additional insured shall be limited to the limits of liability re- quired by that "written contract requiring in- surance". This endorsement shall not in- crease the limits of insurance described in Section III — Limits Of Insurance. b) The insurance provided to the additional in- sured does not apply to "bodily injury", "prop- erty damage" or 'personal injury" arising out of the rendering of, or failure to render, any professional architectural, engineering or sur- veying services, including: The preparing, approving, or failing to prepare or approve, maps, shop draw- ings, opinions, reports, surveys, field or- ders or change orders, or the preparing, approving, or failing to prepare or ap- prove, drawings and specifications; and it. Supervisory, inspection, architectural or engineering activities. c) The insurance provided to the additional in- sured does not apply to "bodily injury" or "property damage" caused by "your work" and included in the "products -completed op- erations hazard" unless the "written contract requiring insurance" specifically requires you to provide such coverage for that additional insured, and then the insurance provided to the additional insured applies only to such "bodily injury" or "property damage" that oc- curs before the end of the period of time for which the "written contract requiring insur- ance" requires you to provide such coverage or the end of the policy period, whichever is earlier. 3. The insurance provided to the additional insured by this endorsement is excess over any valid and collectible 'other insurance", whether primary, excess, contingent or on any other basis, that is available to the additional insured for a loss we cover under this endorsement. However, if the "written contract requiring insurance" specifically requires that this insurance apply on a primary basis or a primary and non-contributory basis, this insurance is primary to 'other insurance" available to the additional insured which covers that person or organization as a named insured for such loss, and we will not share with that "other insurance But the insurance provided to the additional insured by this endorsement still is excess over any valid and collectible 'other in- surance", whether primary, excess, contingent or on any other basis, that is available to the addi- tional insured when that person or organization is an additional insured under such 'other insur- ance". 4. As a condition of coverage provided to the additional insured by this endorsement: a) The additional insured must give us written notice as soon as practicable of an 'occur- rence" or an offense which may result in a claim. To the extent possible, such notice should include: CG D2 46 08 05 0 2005 The St. Paul Travelers Companies, Inc. Page 1 of 2 COMMERCIAL GENERAL LIABILITY i. How, when and where the 'occurrence" or offense took place; ii. The names and addresses of any injured persons and witnesses; and iii. The nature and location of any injury or damage arising out of the "occurrence" or offense. b) If a claim is made or "suit' is brought against the additional insured, the additional insured must: C) d) I. Immediately record the specifics of the claim or "suit' and the date received; and ii. Notify us as soon as practicable. The additional insured must see to it that we receive written notice of the claim or "suit' as soon as practicable. The additional insured must immediately send us copies of all legal papers received in connection with the claim or "suit', cooperate with us in the investigation or settlement of the claim or defense against the "suit', and otherwise comply with all policy conditions. The additional insured must tender the de- fense and indemnity of any claim or "suit' to any provider of "other insurance" which would cover the additional insured for a loss we cover under this endorsement. However, this condition does not affect whether the insur- ance provided to the additional insured by this endorsement is primary to 'other insur- ance" available to the additional insured which covers that person or organization as a named insured as described in paragraph 3. above. 5. The following definition is added to SECTION V. —DEFINITIONS: "Written contract requiring insurance" means that part of any written contract or agreement under which you are required to include a person or organization as an additional in- sured on this Coverage Part, provided that the "bodily injury" and "property damage" oc- curs and the "personal injury" is caused by an offense committed: a. After the signing and execution of the contract or agreement by you; b. While that part of the contract or agreement is in effect; and c. Before the end of the policy period. Page 2 of 2 0 2005 The St. Paul Travelers Companies, Inc. CG D2 46 08 05