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Insurance - Ghai's Tree Services and Landscaping 2017-07-19Policy Number: Date Entered07/19/2017 lll. O CERTIFICATE OF LIABILITY INSURANCE �� DATE 9/2017 7/19/2017 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(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 endorsements . PRODUCER Cheryl Hart—Munoz Insurance 26413 Jefferson Ave Suite F CONTACT NAME: PHONE (951)600-0500 A/C No,(951)332-8000 EODRess: chart2 @£armersagent . cum Murrieta, CA. 92562 05/19/2017 05/19/2018 INSURERS AFFORDING COVERAGE NAIC9 INSURERA:COLONY INSURANCE COMPANY one rnen) $5,000 INSURED Ghai's Tree Service INSURER B: INSURER C: dba GREGORIO HERNANDEZ—MARTINEZ INSURER D: 811 WEST 19TH ST SUITE 522 COSTA MESA, CA 92627 INSURER E: INBURER 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 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. /NSR LT TYPE OF INSURANCE ADDL ifl=SUER WO POLICY NUMBER MMIDDNYPOLICY FF LICY EXP R IDONYYY MM LIMITS A COMMERGAL GENERAL LIABILITY CLAIMS -MADE ® OCCUR �/ X 0076356-00 I 05/19/2017 05/19/2018 ENCE $1,000,000 ocDAMAGE TO RE D currence $100,000 one rnen) $5,000 DV INJURY $1,000,000 MGENERALAGGREGATE GEN'L AGGREGATE LIMIT APPLIES PER: POLICY ❑ PRO ❑ LOC ECT OTHER: REGATE $2,000,000 OMP/OP AGO $2,000,000 $ AUTOMOBILE LIABILITY ANY AUTO OWNED SCHEDULED AUTOS ONLY AUTOS HIRED NON -OWNED AUTOS ONLY AUTOS ONLY COMBINED SINGLE LIMIT $ Ea accident BODILY INJURY (Per person) $ BODILY INJURY (P $ er accident) PROPERTY DAMAGE $ Peraccident UMBRELLA LIAB EXCESS LIAR OCCUR CLAIMS -MADE EACH OCCURRENCE $ AGGREGATE $ DED I I RETENTION $ $ WORKERS COMPENSATION AND EMPLOYERS'LIABILITY YIN ANY PROPRIETOR/PARTNEWEXECUTIVEE.L. OFFICER/MEMBER EXCLUDED? F-1 (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below NIA I PER OTH- STATUTE ER EACH ACCIDENT $ E.L. DISEASE - EA EMPLOYEE $ E.L. DISEASE -POLICY LIMIT $ DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101, Additional Remarks Schedule, maybe attached It more space is required) Costa Mesa Sanitary %stricL their elected and appointed officials, agents, officers, volunteers, and employees fisted M Additional Insured. Pursuant to attached endorsement. 296 Paulalin, AveSHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Costa Mesa, CA 92626 ell� THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE Cheryl Hart—Munoz ACORD 25 (2016/03) ©1988-2015 ACORD CORPORATION. All rights reserved The ACORD name and logo are registered marks of ACORD Produced usina Forms Boss Plus software. www.FormsBoss.com: Impressive Publishina 800-208-1977 101 GL 0076356.00 ENDT. #002 EFF: 07/21/2017 COMMERCIAL GENERAL LIABILITY CG 20 37 04 13 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 PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE PART SCHEDULE Name Of Additional Insured Person(s) Or Organization(s) Location And Description Of Completed Operations Costa Mesa Sanitary District, their elected and 290 Paularino Ave appointed officials, agents, officers, volunteers and Costa Mesa, CA 92626 employees & 290 Paularino Avenue 174 W Wilson Costa Mesa, CA 92626 Costa Mesa, CA 92627 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 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 damage" caused, in whole or in part, by 'your work" at the location designated and described in the Schedule of this endorsement performed for that additional insured and included in the "products -completed operations hazard However: 1. The insurance afforded to such additional insured only applies to the extent permitted by law, and 2. If coverage provided to the additional insured is required by a contract or agreement, the insurance afforded to such additional insured will not be broader than that which you are required by the contract or agreement to provide for such additional insured. B. With respect to the insurance afforded to these additional insureds, the following is added to Section 111— Limits Of Insurance: If coverage provided to the additional insured is required by a contract or agreement, the most we will pay on behalf of the additional insured is the amount of insurance: 1. Required by the contract or agreement; or 2. Available under the applicable Limits of Insurance shown in the Declarations, whichever is less. This endorsement shall not increase the applicable Limits of Insurance shown in the Declarations. CG 20 37 0413 ® Insurance Services Office, Inc., 2012 Page 1 of 1 101 GL 0076356.00 ENDT.#002 EFF: 07121/2017 will not be broader than that which you are required by the contract or agreement to provide for such additional insured. C. With respect to the insurance afforded to these 2. Available under the applicable Limits of additional insureds, the following is added to Insurance shown in the Declarations; Section III — Limits Of Insurance: whichever is less. If coverage provided to the additional insured is This endorsement shall not increase the required by a contract or agreement, the most we Applicable Limits of Insurance shown in The will pay on behalf of the additional insured is the Declarations. amount of insurance: 1. Required by the contract or agreement; or Page 2 of 2 ® Insurance Services Office, Inc., 2012 GG 2010 04 13 POLICYHOLDER COPY SC P.O. BOX 8192, PLEASANTON, CA 94588 CERTIFICATE OF WORKERS' COMPENSATION INSURANCE ISSUE DATE: 12-12-2016 CONTRACTORS STATE LICENSE BOARD WORKERS COMPENSATION UNIT PO BOX 26000 SACRAMENTO CA 95826-0026 eT:iiltl' POLICY NUMBER: 9119755-2016 CERTIFICATE ID: 2 CERTIFICATE EXPIRES: 12-12-2017 12-12-2016/12-12-2017 SC LIC PERMIT#: 999158 INCEPTION DATE:12-12-2016 DO:SC This is to certify that we have issued a valid Workers' Compensation insurance policy in a form approved by the California Insurance Commissioner to the employer named below for the policy period indicated. This policy is not subject to cancellation by the Fund except upon 10 days advance written notice to the employer. We will also give you 10days advance notice should this policy be cancelled prior to its normal expiration. This certificate of insurance is not an insurance policy and does not amend, extend or alter the coverage afforded by the policy listed herein. Notwithstanding any requirement, term or condition of any contract or other document with respect to which this certificate of insurance may be issued or to which it may pertain, the insurance afforded dbbyythe policy described ,herein is subject to all the terms, exclusions, /and conditions, of such policy. ��% JC.7 Authorized Representative President and CEO EMPLOYER'S LIABILITY LIMIT INCLUDING DEFENSE COSTS: $1,000,000 PER OCCURRENCE. ENDORSEMENT #1700 - HERNANDEZ,ABIDAN JAIRO - EXCLUDED. ENDORSEMENT #1700 - HERNANDEZ,GREGORIO - EXCLUDED. EMPLOYER HERNANDEZ, ABIDAN JAIRO (PARTNER) AND HERNANDEZ, GREGORIO (PARTNER) 811 W 19TH ST STE 522 COSTA MESA CA 92627 SC [P1 E, HO] (REV.7-2074) PRINTED : 12-22-2016 A �® CERTIFICATE OF LIABILITY INSURANCE DAM (MMIDDnYrY 08/17/2017 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(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 StateFarm Matt Davenport, Agent State Farm Insurance Inc. ®®„ 547 N Azusa West Covina, CA 91791 CONTACT Aly Santana NAME: PHONE 626-515-7007 ac Nq : 626-486-9278 UDRESS: Aly.Santana.r5bc@statefarm.com INSURERS AFFORDING COVERAGE NAIC# P 909-461-4277 F 909-461-4270 INSURER A: State Farm General Insurance Company 25151 INSURED INSURER B, INSURER C: Ghais Tree Service and Landscape INSURER D: 811 W. 19th St. Ste 522 INSURER E Costa Mesa, CA 92627 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 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 LTR TYPE OF INSURANCE ADDLSUBR POLICY NUMBER POLICY EFF MMO D POLICY EXP MMMD LIMITS COMMERCIAL GENERA -LIABILITY EACH OCCURRENCE $ DAMAGE TO RENTED CLAIMSMAOE OCCUR PREMISES Ea eccurrence $ MEDEXP(Anyoneperson) $ PERSONAL S ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE I $ POLICY L_] JECT PRO- 11 LOG PRODUCTS - COMP/OP AGG $ $ OTHER: AUTOMOBILE LIABILITY 1987 TOYOTA PICK UP COMBINED SINGLE LIMIT $ BODILY INJURY (Per person) $ 15,000 ANY AUTO 373 -5515 -E17 -75C 05-17-2017 11-15-2017 BODILY INJURY (Per accident) $ 30,000 X OWNED SCHEDULED AUTOS ONLY AUTOS HIRED NON -OWNED AUTOS ONLY AUTOSS ONLLYY 1986 TOYOTA 1/2 T LONG PROPERTY DAMAGE $ 25,000 Per acl lision Ded $ Comp/Collision 421 -6852 -E15 -75A 05-17-2017 11-15-2017 UMBRELLA LIAR OCCUR EACH OCCURRENCE $ AGGREGATE $ EXCESS LIAB CLAIMS -MADE DED I I RETENTION$ $ I WORKERS COMPENSATION AND EMPLOYERS' LIABILITY YIN PER OTH- STATUTE ER ANYPROPRIETORJPARTNDED? CUTIVE E.L. EACH ACCIDENT $ OFFICE(Mandatory NIA _ InN NH) In NH) es, E.L. DISEASE - EA EMPLOYEE $ E.L. DISEASE -POLICY LIMIT $ If dere DESCRIPTION OF OPERATIONS below DESCRIPTI DESCRIPTION DESCRIPTION OFOPERATIONS/LOCATIONS/VEHICLES (ACORD 101, Additional Remarks Schedule, maybe aeeched it more apace Is required) Costa Mesa Sanitary District 290 Paularino Ave Costa Mesa, Ca SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE @ 1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD 1001486 132849.12 0&16-2016 a`o2o® CERTIFICATE OF LIABILITY INSURANCE DAT//22017017 Y) 088/17/17 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 State Farm Matt Davenport, Agent State Farm Insurance Inc. ® ®„ 547 N Azusa West Covina, CA 91791 NAMEACT Aly Santana PHONE I) 626-515-7007 AX Net: 626-486-9278 ADDRESS: °'IY@agentdavenpoRcom INSURERS AFFORDING COVERAGE NAIC M P 909-461-4277 F 909-461-4270 INSURERA: State Farm General Insurance Company 25151 INSURED INSURER R: INSURERC: Ghais Tree Service and Landscape INSURERD: 811 W. 19th St. Ste 522 INSURER E: CLAIMS -MADE OCCUR Costa Mesa, CA 92627 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 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 LTR TYPE OF INSURANCE ADDLSUBR POLICYNUMBER POLICYEFF MMIDO POLICY EXP MMIDD LIMITS COMMERCIAL GENERALLIABILITY EACH OCCURRENCE $. DAMAGE TO RENTED CLAIMS -MADE OCCUR PREMISES Ea occurrence $ MED EXP (Anyone person) $ PERSONAL B ADV INJURY $ GENT AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 6 LOC POLICY jECT PRODUCTS - COMP/OP AGG $ $ OTHER: AUTOMOBILE LIABILITY 2006 NISSAN KING CAB CEOMaBINdEEDt SINGLE LIMIT $ BODILY INJURY (Per person) $ 15,000 ANY AUTO 421-1609-1108-75A 05/06/2017 11/08/2017 BODILY INJURY(Peraccimmt) $ 30,000 X OWNED SCHEDULED AUTOS ONLY AUTOS PROPERTY DAMAGE $ 25,000 Per accident HIRED 1,111-01NED AUTOS ONLY AUTOS ONLY Comp/Collision Dad s 500 UMBRELLA LIAR OCCUR EACH OCCURRENCE $ AGGREGATE $ EXCESS LIAB CLAIMS -MADE DED RETENTION $ $ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY YIN PER OTH- STATUTE ER ANY PROPRIETOR/PARTNEWEXECUTIVEE.L. EACH ACCIDENT $ OFFICEWMEMBER EXCLUDED? F—] NIA (Mandatory in NH) E. L. DISEASE - EA EMPLOYE $ If yes, descdbe under DESCRIPTION OF OPERATIONS below E.L. DISEASE -POLICY LIMIT $ I DESCRIPTION OF OPERATIONS / LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) Costa Mesa Sanitary District 290 Paularino Ave Costa Mesa, Ca 92626 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE @ 1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD 1081486 132849.12 03-16-2016