Insurance - Global Power Group, Inc - Workers Comp 2017-04-24aco oR CERTIFICATE OF LIABILITY INSURANCE
L i
DATE(MM/DD/YYYY)
4/24/2017
COVERAGES CERTIFICATE NUMBER: 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.
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 poltcy(ies) must be endorsed. If SUBROGRATION 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 Willis Towers Watson
CONTACT NAME: San Diego
12980 Metcalf Ave Suite 500
PHONE (A/C, No Ext): (858) 314-1100 FAX (A/C, NO): (360) 828-0699
Overland Park KS 66213
EMAIL ADDRESS: Elke.Wohlgemuth@bbsihq.com
INSURER(S) AFFORDING COVERAGE NAIC #
GENERAL LIABILITY
INSURER A: ACE American Insurance Company 22667
INSURER B:
INSURED
Barrett Business Services, Inc. UC/F
INSURER C:
GLOBAL POWER GROUP, INC.
INSURER D:
12060 WOODSIDE AVE
INSURER E:
LAKESIDE, CA 92040
INSURER F:
COVERAGES CERTIFICATE NUMBER: 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
ISSUES 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
LTR
TYPE OF INSURANCE
ADDL
INSR
SUBR
WVD
POLICY NUMBER
POLICYEFF
(MMIDDNYYY)
POLICY EXP
(MMIDD/YYYY)
LIMITS
GENERAL LIABILITY
EACH OCCURRENCE
$
DAMAGE TO RENTED PREMISES (Ee
occurence)
$
COMMERCIAL GENERAL LIABILITY
CLAIMS-MADEEl OCCUR
MED EXP Any one person)
$
PERSONAL &ADV INJURY
$
GENERALAGGREGATE
$
GENT AGGREGATE LIMIT APPLIES PER:
PRODUCTS - COMP/OP AGO
$
POLICY PROJ- LOC
ECT
$
AUTOMOBILE
LIABILITY
COMBINED SINGLE LIMIT
(Ea accident)
$
ANY AUTO
BODILY INJURY (Per person)
$
ALLOWNEDAUTOS SCHEDULED AUTOS
BODILY INJURY (Per accident)
$
HIREDAUTOS NON-OWNEDAUTOS
e
H
PROPERTY DAMAGE
$
$
UMBRELLA LIAB
OCCUR
EACH OCCURRENCE
$
EXCESS LIABOCCUR
AGGREGATE
$
DED
RETENTION $
$
A
WORKERS COMPENSATION AND EMPLOYERS'
LIABILITY YIN
RWC
C64382238
05/01/17
05/01/2018
,/
WC STATU-
TORY LIMITS
GTH-
ER
E.L. EACH ACCIDENT
$2,000,000
ANY PROPRIETORIPARTNER/ EXECUTIVEy
OFFICER/MEMBER EXCLUDED?
N / A
Covered states:
E.L. DISEASE - EA EMPLOYEE
$2,000,000
(Mandatory in NH) If yes, describe under
DESCRIPTION OF OPERATIONS below
CA
E.L. DISEASE- POLICY LIMIT
$2,000,000
DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required)
CERTIFICATE HOLDER
CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE
EXPIRATION DATA THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE
COSTA MESA SANITARY DISTRICT
POLICY PROVISIONS.
290 Paularino Avenue .{ �/�/ 19/1/11
Costa Mesa Ca 92626 V('
AUTHORIZED REPRESENTATIVE
Authorized
Rep
Arrowhead General Insurance Agency
c) 1988-2010 ACORD CORPORATION. All rights reserved.
ACORD 25 (2010105) The ACORD name and logo are registered marks of ACORD.
AGENCY CUSTOMER ID:
LOC: #:
'4� ® ADDITIONAL REMARKS SCHEDULE
AGENCY NAMEDINSURED:
Barrett Business Services, Inc. L/C/F
Arrowhead General Insurance Agency GLOBAL POWER GROUP, INC.
POLICY NUMBER 12060 WOODSIDE AVE
LAKESIDE, CA 92040
RWC 064382238
r`ARRIFR INAIC CODE I
TACE American Insurance Company 122667 (EFFECTIVE DATE: 05/01/17
ADDITIONAL REMARKS
THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM,
FORM NUMBER: 25 FORM TITLE: Certificate of Liability (01/14)
CERTIFICATE HOLDER: COSTA MESA SANITARY DISTRICT
ADDRESS: 290 Paularino Avenue Costa Mesa Ca 92626
Page 2 of 2
RE: All Operations. 30 day notice of cancellation will be provided when possible
ACORD 101 (2008/01) c/'isno-[vw vrcuwrtrvwnvrv.rainynwieaeiveu.
The ACORD name and logo are registered marks of ACORD.