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Insurance - Robotic Sewer Solutions, Inc. 2017-01-25O A�® CERTIFICATE OF LIABILITY INSURANCE DATE(mMmDlvrrrl TYPE OF INSURANCE 1/25/2017 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(ies) 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). PRODUCERCONTACT Bolton &Company 3475 E. Foothill Blvd., Suite 100 Pasadena, CA 91107 NAME: PHC No Ezt: 626 799-7000 ac No: 626 583-2117 EMAIL ADDRESS: INSURERS AFFORDING COVERAGE NAICC 11/22/2017 INSURERA: James River Insurance Company 12203 www.boltonco.com 0008309 INSURED Robotic Sewer Solutions, Inc. 1111 Foothill Boulevard, Suite B La Canada, CA 91011 INSURER B: State Compensation Insurance Fund of CA 35076 INsuRERc: Samsung Fire & Marine Insurance Co. 420022 INSURERD: Torus National Insurance Company 25496 INSURER E; AGGREGATE LIMIT APPLIES PER: POLICY ✓❑ PRI F LOC OTHER: INSURER r: PRODUCTS-COMP/OP AGG $ 2,000,000 rnVC0Aftcc rFRTIFIrATF NIIMRl Q%og000n REVISION NLIMBtR: 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. ILTq TYPE OF INSURANCE ADDL SUER won POLICYNUMBER MMOUYEFF MMLpY EXP LIMITS A �/ COMMERCIAL GENERAL LIABILITY CLAIMS -MADE OCCUR Per Project Aggregate �/ 000506276 11/22/2016 11/22/2017 EACH OCCURRENCE $ 1,000,000 DAMAGE TO RENTED 50,000 PREMISa urrenceES occ$ E ✓ ✓ GEN'L MED EXP (Any one person) $ Excluded Capped at $10,000,000 PERSONAL & AOV INJURY $ 1,000,000 AGGREGATE LIMIT APPLIES PER: POLICY ✓❑ PRI F LOC OTHER: GENERAL AGGREGATE $ 2,000,000 PRODUCTS-COMP/OP AGG $ 2,000,000 $ C AUTOMOBILE LIABILITY / ANY AUTO OWNED SCHEDULED AUTOS ONLY AUTOS HIRED NON, NED AUTOS ONLY AUTOS ONLY ✓ CPP006406404 8/1/2016 8/1/2017 OMBI EDtSINGLE LIMIT $ 1000,000 Ea BODILY INJURY (Per person) $ BODILY INJURY (Par accidmt) $ PROPERTY DAMAGE $ Per sccitlenl D 1/ UMBRELLALIAB EXCESS LIAB N OCCUR CLAIMS -MADE 87446H163ALI 11/22/2016 11/22/2017 EACH OCCURRENCE $ 4,000,000 AGGREGATE $ 4,000;000 DED I ✓ I RETENTION$0 I $ B WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANYPROPRIETORIPARTNEWEXECUTIVE YIN OFFICERIMEMBEREXCLUDED? (Mandatory In NH) If yes, describe under DESCRIPTION OF OPERATIONS below NIA 198026416 11/22/2016 11/22/2017 �/ STATUTE ETH E.L. EACH ACCIDENT $ $1,000,000 E.L. DISEASE - EA EMPLOYEE $ $1000,000 E.L. DISEASE -POLICY LIMIT $ $1,000,000 DESCRIPTION OF OPERATIONS /LOCATIONS /VEHICLES (ACORD 101, Additional Remarks Schedule, maybe attached if more space is Smutted) GL Additional Insured applies per CG20120798 attached, only if required by written contmctlagreement. Auto Additional Insured applies per SS03010111 attached. Additional Insured(s): The Costa Mesa Sanitary District, it's elected and appointed officials, agents, officers, volunteers and employees. The Certificate of Insurance is subject to policy terms, conditions, limitations and exclusions. c nrrcrr.Tc unr mco rA1Ur F1 I ATInIU Costa Mesa Sanitary District 290 Paularino Avenue G 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, CA 92626 %I;b1 AUTHORIZEDREPRESENTATIVE Melonie Harbo U 1986-2015 AGURD OUKFUKA I ION. An ngms reserveG. ACORD 25 (2016103) The ACORD name and logo are registered marks of ACORD 33932990 1 ROHOSEW-01 1 16-17 GL, XS & WC, 16-17 AUTO I Smmon Smith 11/25/2017 2:99:39 IN (PDT) I Page 1 of 5 POLICY NUMBER: 00050627-6 COMMERCIAL GENERAL LIABILITY CG 20 12 05 09 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - STATE OR GOVERNMENTAL AGENCY OR SUBDIVISION OR POLITICAL SUBDIVISION - PERMITS OR AUTHORIZATIONS This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE State Or Governmental Agency Or Subdivision Or Political Subdivision: The Costa Mesa Sanitary District, it's elected and appointed officials, agents, officers, volunteers, and employees Information required to complete this Schedule, if not shown above, will be shown in the Declarations. Section II — Who Is An Insured is amended to in- clude as an insured any state or governmental agen- cy or subdivision or political subdivision shown in the Schedule, subject to the following provisions: 1. This insurance applies only with respect to opera- tions performed by you or on your behalf for which the state or governmental agency or subdivision or political subdivision has issued a permit or author- ization. 2. This insurance does not apply to: a. "Bodily injury", "property damage" or "personal and advertising injury" arising out of operations performed for the federal government, state or municipality, or b. "Bodily injury" or "property damage" included within the "products -completed operations hazard". CG 20 12 05 09 © Insurance Services Office, Inc., 2008 Page 1 of 1 ❑ 33932990 1 Roeoskw-01 1 16 17 cL xs a WC, 16 17 AP,o I Si,__ smith 1 1/21/20v 2A1,13 114 (Pox) 1 Page 1 o£ s CPP006406404 COMMERCIAL AUTO EXTENSIVE ENDORSEMENT 3303010111 COMMERCIAL AUTO EXTENSIVE ENDORSEMENT THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. This endorsement modifies insurance provided under the following: BUSINESS AUTO COVERAGE FORM SECTION II - LIABILITY COVERAGE A.COVERAGE 1. WHO IS AN INSURED The following is added: d. Any organization, other than a partnership or joint venture, over which you maintain ownership or a majority interest on the effective date of this Coverage Form, if there is no similar insurance available to that organization. e. Any organization you newly acquire or form other than a partnership or joint venture, and over which you maintain ownership of a majority interest. However, coverage under this provision does not apply: (1) If there is similar insurance or a self- insured retention plan available to that organization; or (2) To "bodily injury" or "property damage" that occurred before you acquired or formed the organization. f. Any volunteer or employee of yours while using a covered "auto" you do not own, hire or borrow in your business or your personal affairs. Insurance provided by this endorsement is excess over any other insurance available to any volunteer or employee. g. Any person, organization, trustee, estate or governmental entity with respect to the operation, maintenance or use of a covered "auto" by an insured, if: (a) an expressed provision of an "insured contract", or written agreement; or (b) an expressed condition of a written permit issued to you by a governmental or public authority. 2) The "bodily injury" or "property damage" is caused by an "accident" which takes place after: (a) You executed the "insured contract" or written agreement; or (b) the permit has been issued to you 2. COVERAGE EXTENSIONS a. Supplementary Payments. Subparagraphs (2) and (4) are amended as follows: (2) Up to $2500 for cost of bail bonds (including bonds for related traffic law violations) required because of an "accident' we cover. We do not have to furnish these bonds. (4) All reasonable expenses incurred by the "Insured" at our request, including actual loss of earning up to $500 a day because of time off from work. SECTION III - PHYSICAL DAMAGE COVERAGE A. COVERAGE The following is added: 5. Hired Auto Physical Damage (1) You are obligated to add that person, a. Any "auto" you lease, hire, rent or borrow organization, trustee, estate or governmental from someone other than your employees or entity as an additional insured to this policy partners or members of their household is a by: covered "auto" for each of your physical damage coverages. SS 03 01 01 11 Includes copyrighted material of Insurance Services Offices, Inc. with its permission Page 1 of 3 33932990 1 ROBOSEW-01 116-1] GL, %S E WC, 16-17 ffi 0 I Shannon Smith 1 1/25/2019 2:49:39 PM (POT( I Page 2 of 5 b. The most we will pay for "loss" in any one "accident" is the smallest of: (1) $50,000 (2) The actual cash value of the damaged or stolen property as of the time of the "loss"; or (3) The cost of repairing or replacing the damaged or stolen property with other property of like kind and quality. If you are liable for the "accident", we will also pay up to $500 per "accident" for the actual loss of use to the owner of the covered "auto". c. Our obligation to pay for, repair, return or replace damaged or stolen property will be reduced by an amount that is equal to the amount of the largest deductible shown for any owned "auto" for that coverage. However, any Comprehensive Coverage deductible shown in the Declarations does not apply to "loss" caused by fire or lightning. d. For this coverage, the insurance provided is primary for any covered "auto" you hire without a driver and excess over any other collectible insurance for any covered "auto" that you hire with a driver. 6. Rental Reimbursement Coverage We will pay up to $75 per day for up to 30 days, for rental reimbursement expenses incurred by you for the rental of an "auto" because of "loss" to a covered "auto". Rental Reimbursement will be based on the rental of a comparable vehicle, which in many cases may be substantially less than $75 per day, and will only be allowed for a period of time it should take to repair or replace the vehicle with reasonable speed and similar quality, up to a maximum of 30 days. We will also pay up to $500 for reasonable and necessary expenses incurred by you to remove and replace your materials and equipment from the covered "auto". If "loss" results from the total theft of a covered "auto" of the private passenger type, we will pay under this coverage only that amount of your rental reimbursement expenses which is not already provided under paragraph 4. Coverage Extension. COMMERCIAL AUTO EXTENSIVE ENDORSEMENT SS 03 01 01 11 7. Lease Gap Coverage If a long-term leased "auto" is a covered "auto" and the lessor is named as an Additional Insured - Lessor, In the event of a total loss, we will pay your additional legal obligation to the lessor for any difference between the actual cash value of the "auto" at the time of the loss and the "outstanding balance" of the lease. "Outstanding balance" means the amount you owe on the lease at the time of loss less any amounts representing taxes; overdue payments; penalties, interest or charges resulting from overdue payments; additional mileage charges; excess wear and tear charges; and lease termination fees. B. EXCLUSIONS The following is added to Paragraph 3 The exclusion for "loss" caused by or resulting from mechanical or electrical breakdown does not apply to the accidental discharge of an airbag. Paragraph 4 is replaced with the following: 4. We will not pay for "loss" to any of the following: a. Tapes, records, disks or other similar audio, visual or data electronic devices designed for use with audio, visual or data electronic equipment. b. Equipment designed or used for the detection or location of radar. c. Any electronic equipment that receives or transmits audio, visual or data signals. Exclusion 4.c does not apply to: (1) Electronic equipment that receives or transmits audio, visual or data signals, whether or not designed solely for the reproduction of sound, if the equipment is permanently installed in the covered "auto" at the time of the "loss" and such equipment is designed to be solely operated by use of the power from the "auto's" electrical system, in or upon the covered "auto"; or (2) Any other electronic equipment that is: SS 03 01 01 11 Includes copyrigtded material of Insurance services Offices, Inc. with its permission 33932990 1 ROBOSEW-01 1 16-17 GL, XS & WC, 16-17 AOTO I Shannon Smith 1 1/25/2017 2:49:39 PM (POT) I Page 3 Of 5 Page 2 of 3 (a) Necessary for the normal operation of the covered "auto" or the monitoring of the covered "auto's"operating system; or (b) An integral part of the same unit housing any sound reproducing equipment described in (1) above and permanently installed in the opening of the dash or console of the covered 'auto" normally used by the manufacturer for installation of a radio. D. DEDUCTIBLE The following is added: No deductible applies to glass damage if the glass is repaired rather than replaced. SECTION W. BUSINESS AUTO CONDITIONS A. LOSS CONDITIONS Item 2.a. and b. are replaced with: 2.Duties In The Event of Accident, Claim, Suit, or Loss a. You must promptly notify us. Your duty to promptly notify us is effective when any of your executive officers, partners, members, or legal representatives is aware of the accident, claim, "suit", or loss. Knowledge of an accident, claim, "suit", or loss, by other employee(s) does not imply you also have such knowledge. b. To the extent possible, notice to us should include: (1) How, when and where the accident or loss took place; (2) The names and addresses of any injured persons and witnesses; and (3) The nature and location of any injury or damage arising out of the accident or loss. The following is added to 6 We waive any right of recovery we may have against any additional insured under Coverage A. 1. Who Is An Insured g., but only as respects loss arising out of the operation, maintenance or use of a covered "auto" pursuant to the provisions of the "insured COMMERCIAL AUTO EXTENSIVE ENDORSEMENT SS 03 01 01 11 contract", written agreement, or permit. B. GENERAL CONDITIONS 9. is added 9. UNINTENTIONAL FAILURE TO DISCLOSE HAZARDS Your unintentional failure to disclose any hazards existing at the effective date of your policy will not prejudice the coverage afforded. However, we have the right to collect additional premium for any such hazard. COMMON POLICY CONDITIONS 2.b. is replaced by the following: b. 60 days before the effective date of cancellation if we cancel for any other reason. SS 03 01 01 11 Includes copyrighted material of Insurance Services Offices, Inc. with its permission 33932990 1 ROBOSEW-01 116-17 GL, %5 & WC, 16-17 AUTO I ShaMOn Smith 11/25/2017 2;49:39 PM (POT) I Page 4 of 5 Page 3 of 3