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Insurance - Robotic Sewer Solutions, Inc. - 2017-03-13
• ACO® DATE(MWDOMYYY) `� CERTIFICATE OF LIABILITY INSURANCE 3/13/2017 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). PRODUCER Bolton&Company NACT 3475 E. Foothill Blvd., Suite 100 PHONE Ext), (626)799-7000 FAX No): (626)583-2117 Pasadena, CA 91107 L ADDRESS: INSURER(S)AFFORDING COVERAGE NAIC I www.bottonco.com 0008309 INSURER A: James River Insurance Company' 12203 INSURED INSURER B: State Compensation Insurance Fund of CA" 35076 1111 Robotic Sewer Solutions,Suit INSURERC: Samsung Fire&Marine Insurance Co. 1 420022 1111 Foothill Boulevard, Suite B La Canada, CA 91011 INSURER D: Torus National Insurance Company / 25496 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: 34635908 REVISION NUMBER: 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 ADDL SUBR POLICY EFF POUCY EXP LIR TYPE OF INSURANCE WSD MID POUCY NUMBER (MMIDD/YYYYI (MM/DD/YYYY) LIMITS A ✓ COMMERCIAL GENERAL LIABILITY ✓ 000506276 11/22/2016 11/22/2017 EACH OCCURRENCE $ 1,000,000 DAMAGE TO CLAIMS-MADE I OCCUR PREMISES(EaENTED occurrence) $ 50,000 / Per Project Aggregate MED EXP(Any one person) $ Excluded _ ,/ Capped at$10,000,000 PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 POLICY ✓ JPERo- LOC PRODUCTS-COMP/OP AGG $ 2,000,000 OTHER: $ C AUTOMOBILELIABILITY CPP006406404 8/1/2016 8/1/2017 (EeMBBIINEED(SINGLELIMIT $ 1,000,000 ✓ ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS HIRED NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY _ AUTOS ONLY (Per accident) $ D UMBRELLA UAB I OCCUR 87446H163ALI 11/22/2016 11/22/2017 EACH OCCURRENCE $ 4,000,000 ✓ EXCESS UAB CLAIMS-MADE AGGREGATE $ 4,000,000 DED ✓ RETENTION$0 $ B WORKERS COMPENSATION ✓ 198026416 11/22/2016 11/22/2017 ✓ STATUTE ETH- AND EMPLOYERS'LIABILITY Y/N ANYPROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ $1,000,000 OFFICER/MEMBER EXCLUDED? n N/A (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $ $1,000,000 Ir yes,desaibe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ $1,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached N more space Is required) GL Additional Insured applies per form CG20100704&CG20370704 attached,only if required by written contract/agreement. GL Primary wording applies per AP5031 US(04-10)attached.Re:#314 Grade 5 Repairs Phase 7. Additional Insured(s):Costa Mesa Sanitary District,its directors,officials,officers,employees,agents,and volunteers. The Certificate of Insurance is subject to policy terms,conditions,limitations and exclusions. CERTIFICATE HOLDER CANCELLATION #314 Grade 5 Repairs Phase 7 Costa Mesa Sanity District SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Co Paularinoesa Sanitary THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 29Costa Mesa, CA 92626eACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZEDREPRESENTATNE I Melonie Harbo .fgao..s,...: AIL, ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD 34635908 I ROBOSEW-01 116-17 GL, XS & WC, 16-17 AUTO I Bolton Certificate Processing 13/13/2017 6:07:49 PM (PDT) 1 Page 1 of 4 • POLICY NUMBER: 000506276 COMMERCIAL GENERAL LIABILITY CG 20 10 07 04 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 SCHEDULE Name of Additional Insured Person(s) or Organization(s): Locations(s)of Covered Operations Where Required By Written Contract Or Agreement All Projects Of The Named Insured Information required to complete this Schedule, if not shown above, will be shown in the Declarations. A. Section II — Who Is An Insured is amended to B. With respect to the insurance afforded to these include as an additional insured the person(s) or additional insureds, the following additional exclu- organization(s) shown in the Schedule, but only with ions apply: respect to liability for "bodily injury", "property This insurance does not apply to "bodily injury" or damage"or"personal and advertising injury' caused, in whole or in part, by: "property damage"occurring after: 1. Your acts or omissions; or 1. All work, including materials, pads or equip- ment furnished in connection with such work, 2. The acts or omissions of those acting on your on the project (other than service, maintenance behalf; or repairs) to be performed by or on behalf of in the performance of your ongoing operations for the additional insured(s) at the location of the the additional insured(s) at the location(s) desig- nated above. 2. That portion of "your work" out of which the injury or damage arises has been put to its in- tended use by any person or organization other than another contractor or subcontractor en- gaged in performing operations for a principal as a part of the same project. CG 20 10 07 04 ©ISO Properties, Inc.,2004 Page 1 of 1 34635908 1 ROHOSEW-01 1 16-17 GL, XS E. WC, 16-17 AUTO 1 Bolton Certificate Processing 1 3/13/2017 6:07:49 PM (PDT) 1 Page 2 of 4 POLICY NUMBER: 000506276 COMMERCIAL GENERAL LIABILITY CG 20 37 07 04 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 SCHEDULE Name of Additional Insured Person(s) or Organization(s): Locations and Description of Covered Operations Where Required By Written Contract Or Agreement All Projects Of The Named Insured 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 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 dam- age" caused, in whole or in part, by "your work' at the location designated and described in the sched- ule of this endorsement performed for that additional insured and included in the "products-completed operations hazard." ISI CG 20 37 07 04 ©ISO Properties, Inc., 2004 Page 1 of 1 34635908 1 ROBOSEW-01 1 16-17 GL, XS & WC, 16-17 AUTO 1 Bolton Certificate Processing 1 3/13/2017 6:07:49 PM (PDT) 1 Page 3 of 4 • 000506276 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. PRIMARY AND NON CONTRIBUTORY ENDORSEMENT This endorsement modifies insurance provided under the following: ALL COVERAGE PARTS Name Of Additional Insured Person(s) Or Organization(s): Where Required By Written Contract or Agreement If no entry appears above, this endorsement applies to all Additional Insureds covered under this policy. Any coverage provided to an Additional Insured under this policy shall be excess over any other valid and collectible insurance available to such Additional Insured whether primary, excess, contingent or on any other basis unless a written contract or written agreement specifically requires that this insurance apply on a primary and noncontributory basis. ALL OTHER TERMS AND CONDITIONS OF THE POLICY REMAIN UNCHANGED. AP5031 US 04-10 Page 1 of 1 34635908 1 ROBOSEW-01 1 16-17 GL, XS & WC, 16-17 AUTO 1 Bolton Certificate Processing 1 3/13/2017 6:07:49 PM (PDT) 1 Page 4 of 4 James River Insurance Company - Company Profile - Best's Credit Rating Center Page 1 of 3 A.M. Best Rating Services James River Insurance Company (?) A.M.Best#:012604 NAIC#:12203 FEIN#:222824607 Mailing Address View Additional Address Information P.O.Box 27648 Richmond,VA 23261 A United States Assigned to insurance companies that have,in our opinion,an excellent ability Web:www.iamesriverins.com to meet their ongoing insurance Phone:804-289-2700 obligations. Fax:804-420-1054 View additional news,reports and products for this company. Based on A.M.Best's analysis,055488-James River Group Holdings,Ltd.is the AMB Ultimate Parent and identifies the topmost entity of the corporate structure.View a list of operating insurance entities in this structure. Best's Credit Ratings Financial Strength Rating View Definition Rating: A(Excellent) Affiliation Code: g(Group) Financial Size Category: IX($250 Million to$500 Million) Outlook: Stable Action: Upgraded Effective Date: July 29,2016 Initial Rating Date: July 03,2003 Long-Term Issuer Credit Rating View Definition Long-Term: a Outlook: Stable Action: Upgraded Effective Date: July 29,2016 Initial Rating Date: November 18,2005 u Denotes Under Review Bests Rating Best's Credit Rating Analyst Rating Issued by:A.M.Best Rating Services,Inc. Senior Financial Analyst:Robert Raber Senior Director:Gregory T.Williams Disclosure Information FDF EftViewA.M.Best's Rating Disclosure Form A.M.Best Upgrades Ratings of JRG Reinsurance Company,Ltd.and Its Affiliates -r•-- July 29,2016 Rating History A.M.Best has provided ratings&analysis on this company since 2003. http://www3.ambest.com/ratings/entities/CompanyProfile.aspx?ambnum=12604&URating... 4/11/2017 List of Approved Surplus Line Insurers (LASLI) Page 4 of 7 Houston Specialty Insurance Company (Texas) 10/08/2009 (Name changed from Naxos Insurance Company effective 12/30/10) (Domicile changed from Delaware to Texas effective 12/30/2011) HSB Specialty Insurance Company (Connecticut) 09/26/2013 Hudson Specialty Insurance Company (New York) 11/09/1995 (Name changed from General Security Indemnity Company effective 12/29/03) Illinois Union Insurance Company (Illinois) 12/22/1995 Indian Harbor Insurance Company (Delaware) 12/08/1995 (Domicile changed from North Dakota to Delaware effective 07/01/2013) International Insurance Company of Hannover SE (Germany) 09/29/1998 (Name changed from International Insurance Company of Hannover PLC effective 07/15/2014) (Name changed from International Insurance Company of Hannover Ltd effective 08/07/2013) (Domicile changed from United Kingdom to Germany effective 01/05/2015) Interstate Fire & Casualty Company (Illinois) 10/20/1995 Ironshore Insurance Ltd. (Bermuda) 07/20/2011 Ironshore Specialty Insurance Company (Arizona) 10/02/2008 James River Insurance Company (Ohio) 08/04/1995 (Name changed from Fidelity Excess and Surplus Insurance Company effective 07/07/03) Lancashire Insurance Company (UK) Limited (U.K.) 11/17/2010 Lancashire Insurance Company Limited (Bermuda) 11/19/2009 Landmark American Insurance Company (New Hampshire) 09/30/2003 (Domicile changed from Oklahoma to New Hampshire effective October 28, 2016 Lexington Insurance Company (Delaware) 07/28/1995 Liberty Mutual Insurance Europe Limited (U.K.) 10/27/1995 (Name changed from Liberty Mutual Insurance (U.K.) Limited effective 10/21/2003) Liberty Surplus Insurance Corporation (New Hampshire) 12/18/1997 Back to Top M - P Insurer Date Approved The Marine Insurance Company Limited (UK) 11/03/1995 Markel International Insurance Company Limited (U.K.) 10/27/1995 (Name changed from Terra Nova Insurance Company Limited, effective 11/04/2002) Maxum Indemnity Company (Connecticut) 09/29/1998 (Domicile changed from Delaware to Connecticut effective December 1, 2016) (Name changed from Caliber One Indemnity Company, effective 01/02/2003) Mercer Insurance Company (Pennsylvania) 06/10/2016 http://www.insurance.ca.gov/01-consumers/120-company/07-lasli/lasli.cfm 4/11/2017 Company Profile Page 1 of 1 CAL FORN A DEPARTMENT OF INSURANCE COMPANY PROFILE Company Profile Company Search Company Information Company Search Results STATE COMPENSATION INSURANCE FUND Company PO BOX 8192 Information PLEASANTON, CA 94588-8792 Old Company 877-405-4545 Names Agent for Service Old Company Names Effective Date Reference Information NAIC Group List Agent For Service Lines of Business CORPORATE LEGAL Workers' STATE COMPENSATION INSURANCE FUND Compensation 5880 OWENS DRIVE, 3RD FLOOR Complaint and PLEASANTON CA 94588 Request for Action/Appeals Contact Information Reference Information Financial Statements PDF's NAIC#: 35076 Annual Statements California Company ID #: 0449-9 Quarterly Statements Date Authorized in California: 01/01/1914 Company Complaint License Status: UNLIMITED-NORMAL Company Performance& Company Type: Property&Casualty Comparison Data Company State of Domicile: CALIFORNIA Enforcement Action Composite back to top Complaints Studies Additional Info Find A Company NAIC Group List Representative In Your Area View Financial NAIC Group #: 0000 Disclaimer Lines Of Business The company is authorized to transact business within these lines of insurance. For an explanation of any of these terms, please refer to the glossary. WORKERS'COMPENSATION back to top © 2008 California Department of Insurance https://interactive.web.insurance.ca.gov/companyprofile/companyprofile?event=companyP... 4/11/2017 Samsung Fire & Marine Insurance Co., Ltd. - Company Profile - Best's Credit Rating Cen... Page 1 of 3 A.M. Best Rating Services Samsung Fire & Marine Insurance Co., Ltd. (2) A.M.Best#:085850 AIIN#:AA5420022 Stock Ticker:Korea Stock Exchange KRX A00810 Domiciliary Address Samsung Insurance Building 29 Euljiro 1-ga Jung-gu a 100-782 Seoul, Assigned to insurance companies that South Korea have,in our opinion,a superior ability to meet their ongoing insurance obligations. Web:www.samsunefire.com Phone:82-2-1588-5114 Fax:82-2-758-7831 View additional news,reports and products for this company. Based on A.M.Best's analysis,085850-Samsung Fire&Marine Insurance Co,Ltd is the AMB Ultimate Parent and identifies the topmost entity of the corporate structure.View a list of operating insurance entities in this structure. Best's Credit Ratings Financial Strength Rating View Definition Rating: A++(Superior) Financial Size Category: XV($2 Billion or greater) Outlook: Stable Action: Affirmed Effective Date: September 23,2016 Initial Rating Date: April 20, 1998 Long-Term Issuer Credit Rating View Definition Long-Term: aa+ Outlook: Stable Action: Affirmed • Effective Date: September 23,2016 Initial Rating Date: November 30,2005 u Denotes Under Review Best's Rating Best's Credit Rating Analyst Rating Issued by:A.M.Best Asia-Pacific Ltd. Associate Financial Analyst:Sergio Agena Associate Director-Analytics:Seewon Oh Disclosure Information FDF4EftView A.M.Best's Rating Disclosure Form A.M.Best Affirms Credit Ratings of Samsung Fire&Marine Insurance Co., Ltd.and Its Subsidiaries September 23,2016 Rating History A.M.Best has provided ratings&analysis on this company since 1998. http://www3.ambest.com/ratings/entities/CompanyProfile.aspx?ambnum=85850&URating... 4/11/2017 Company Profile Page 1 of 2 CALIRORN`A DEPARTMENT OF INSURANCE COMPANY PROFILE Company Profile Company Search Company Information Company Search Results SAMSUNG FIRE&MARINE INSURANCE CO., LTD. (UNITED STATES BRANCH) Company 105 CHALLENGER ROAD,STH FLOOR Information RIDGEFIELD PARK, NJ 07660 Old Company 866-898-9991 Names Agent for Service Old Company Names Effective Date Reference Information NAIC Group List Agent For Service Lines of Business Theresa Ramos Workers' 1 Market Street Compensation Suite 3560 Complaint and San Francisco CA 94105 Request for Action/Appeals Contact Information Reference Information Financial Statements PDF's NAIC#: 38300 Annual Statements California Company ID #: 4465-1 Quarterly Statements Date Authorized in California: 11/14/1997 Company Complaint License Status: UNLIMITED-NORMAL Company Performance& Company Type: Property&Casualty Comparison Data Company State of Domicile: NEW YORK Enforcement Action Composite back to top Complaints Studies Additional Info Find A Company NAIC Group List Representative In Your Area View Financial NAIC Group #: 0000 Disclaimer Lines Of Business The company is authorized to transact business within these lines of insurance. For an explanation of any of these terms, please refer to the glossary. AIRCRAFT AUTOMOBILE BOILER AND MACHINERY BURGLARY COMMON CARRIER LIABILITY • FIRE LEGAL INSURANCE LIABILITY MARINE MISCELLANEOUS PLATE GLASS SPRINKLER TEAM AND VEHICLE https://interactive.web.insurance.ca.gov/companyprofile/companyprofile?event=companyP... 4/11/2017 StarStone National Insurance Company- Company Profile -Best's Credit Rating Center Page 1 of 3 A.M. Best Rating Services StarStone National Insurance Company A.M.Best#:002512 NAIC#:25496 FEIN#:951429618 Administrative Office View Additional Address Information PI Harborside Plaza 5 185 Hudson Street <MO Suite 2600 A„ Jersey City,NJ 07311 Assigned to insurance companies that United States have,in our opinion,an excellent ability to meet their ongoing insurance Web:www.starstone.com obligations. Phone:201-743-7700 Fax:201-743-7701 View additional news,reports and products for this company. Based on A.M.Best's analysis,055579-Enstar Group Limited is the AMB Ultimate Parent and identifies the topmost entity of the corporate structure.View a list of operating insurance entities in this structure. Best's Credit Ratings Financial Strength Rating View Definition Rating: A-(Excellent) Affiliation Code: g(Group) Financial Size Category: XI($750 Million to$1 Billion) Outlook: Stable Action: Affirmed Effective Date: June 10,2016 Initial Rating Date: June 30, 1949 Long-Term Issuer Credit Rating View Definition Long-Term: a- Outlook: Stable Action: Affirmed Effective Date: June 10,2016 Initial Rating Date: May 20,2005 u Denotes Under Review Best's Rating Best's Credit Rating Analyst Rating Issued by:A.M.Best Rating Services, Inc. Senior Financial Analyst:Scott Mangan Director:Greg Reisner Disclosure Information FDFAView A.M.Best's Rating Disclosure Form .144:- A.M.Best Affirms Ratings of StarStone Insurance Bermuda Limited and Its Subsidiaries p June 10,2016 Rating History A.M.Best has provided ratings&analysis on this company since 1949. http://www3.ambest.com/ratings/entities/SearchResults.aspx?URatingId=2588176&b1=0&... 4/11/2017 Company Profile Page 1 of 2 CALIFORN DEPARTMENT OF INSURANCE COMPANY PROFILE Company Profile Company Search Company Information Company Search Results STARSTONE NATIONAL INSURANCE COMPANY Company HARBORSIDE 5, 185 HUDSON STREET Information JERSEY CITY, NJ 07311 Old Company 800-220-8477 Names Agent for Service Old Company Names Effective Date Reference Information OLYMPIC INS CO 01/01/1981 NAIC Group List TIG INDEMNITY COMPANY 11/17/2010 Lines of Business TORUS NATIONAL INSURANCE COMPANY 12/01/2015 Workers' TRANSAMERICA INDEMNITY COMPANY 09/24/1993 Compensation Complaint and Agent For Service Request for Action/Appeals Vivian Imperial Contact Information 818 WEST SEVENTH STREET SUITE 930 Financial Statements LOS ANGELES CA 90017 PDF's Annual Statements Quarterly Reference Information Statements , , Company Complaint NAIC#: 25496 Company California Company ID #: 1291-4 Performance& Comparison Data Date Authorized in California: 12/29/1944 Company Enforcement Action License Status: UNLIMITED-NORMAL Composite Complaints Studies Company Type: Property&Casualty Additional Info State of Domicile: DELAWARE Find A Company Representative In Your Area back to top View Financial Disclaimer NAIC Group List NAIC Group #: 4725 Enstar Grp Lines Of Business The company is authorized to transact business within these lines of insurance. For an explanation of any of these terms, please refer to the glossary. AIRCRAFT BOILER AND MACHINERY BURGLARY COMMON CARRIER LIABILITY CREDIT DISABILITY FIRE LIABILITY MARINE https://interactive.web.insurance.ca.gov/companyprofile/companyprofile?event=companyP... 4/1 1/2017