Insurance - C & R Drains - Workers Comp - 2017-09-1309/20/2017 03:41PM 7146413189 PAGE 02/02
ACOR& CERTIFICATE OF LIABILITY INSURANCE—
IMMMONYYY)
TYPSOFINSURANce
09/13/2017
THIS CERTIFICATE Is ISSUED ASA 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 previsions or be endorsed.
If SUBROGATION IS WAIVED, subject to the terms And conditions of the pollcy, 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
CONTACTKorean Borwege
NAME
Primary Source Insurance Agency Inc
121 E Park Square
a� rEP (800)700-2809 q1C No : (877)446-4631
EMAIL KMBOrw ¢ fadiRS.Com
400RE99r
INSURERS AFFORDING COVERAGE NAICa
Owatonna MN 55000
INSUREAA: Security National Insurance Company 15879
INSURED
INSURERS:
C & R Drains Inc
INSURER C:
1525 Wast Macarthur Blvd Ste 11
MISURERD;
INSURERE:
AUTOMOBILE
Costa Masa CA 9262@.1413
INSURER F:
COVERAGES CERTIPICATENDM9ER• i7-16 WG oMmnu uuuoco.
THIS ISTO CERTIFYTHATTHE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUEDTO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED- NOTNATHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACTOR OTHER DOCUMENT WITH RESPECTTO WHICH THIS
CERTIFICATE MAYBE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECTTO ALLTHE TERMS,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
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TYPSOFINSURANce
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DONMEROIAL GENERAL UABIUTY
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AUTHORIZEDREPRESEM111E
COSTAMESA
CA 926?6
EACH OCCURRENCE E
PREMISES Fa dccundnm 3
MED EXP An oro E
PERSONALaADV INJURY INJURY E
GEML AGGREGATE UMITAPPUES PER
❑ PRO- F-1POLICY JECT LOC
OTHER:
DENERALAGGREGATE E
PRODUCTS -COMPiOP qGG E
I
AUTOMOBILE
LIABILITY
ANYAUTO
OWNED 9CHEOULEO
AUTOGONLY AUTOS
HIRED NON-OWNSO
AUTOS ONLY AVTOS ONLY
COMBINED SINGLE UMIT E
fee ar<Men
BODILY INJURY (PmparadP) E
BODILY INJURY PorauideM E
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PROPERTY DAMAGE
Pdrattitldnl S
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EXCESS LIAR
OCCUR
CVJMS-MAOE
EACH OCCURRENCE S
AGGREGATE S
OED I I RETENTION S
E
A
WORKERS COMPENSATIONPER
AND EMPLOYERS LIABILITY VIN
CUE
ANY PROPRIETORPARTNER/E%eTIV
OPBOERIMEMaER GXCLUDEDT
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It yes, deeMbe NDier
DESCRIPTION OF OPERATIONS ball.
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$WC1167371
09/10/2017
09/10/2018
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E.L EACHACCIDENT E 1.000,000
E.LDL9RA5R-EAEMPLOYEE E 1,000,000
EL DISEASE- POLICY LIMIT E 1,000,000
DEGCRIPT(ON OF OPERAnONS/ LOCATIONS /VEHICLES (/KORO 101, Addlllonal ReMQH - SareOUla, May baaM hw It Mdre spam 1. required)
CERTIFICATE HOLDER CANCELLATION
®1988.2016 ACORD CORPORATION. All rights reserved.
ACORD 25 (2016103) The ACORD name and logo are registered marks of ACORD
SHOULDANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
COSTA MESA SANITARY DISTRICT
ACCORDANCE WITH THA POLICY PROVISIONS-
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AUTHORIZEDREPRESEM111E
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CA 926?6
®1988.2016 ACORD CORPORATION. All rights reserved.
ACORD 25 (2016103) The ACORD name and logo are registered marks of ACORD