Insurance - Kasprzyk, Theresa R. - 2017-09-20A� CERTIFICATE OF LIABILITY INSURANCE °Aa orcvrYl
THIS. CERTIFICATE 15 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), AU114ORIZED
REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER.
IMPORTANT: it the certificate holder Is an ADDITIONAL INSURED, the pollcy(los) must have ADDITIONAL INSURED provislons or be endorsed.
If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain poll4les may require an endaraenrI A statement on
this certificate does not confer rights to the certificate holder in lieu of such endorsement 5 .
PRODUCER
CONTACT
,NAMEi ._._—
PRO" 7T4S953022 FAX
State€arm STATE FARM INSURANCE
R REESE, AGENT
M19-EA).
-u.EMj'
EMAIL
�fj
ADD ESS:
8130 MCFAODEN AVE SUITE205
_ IN5VaERl51AFFORDING CDVFJNGE NAIC4
WESTMINSTER, CA 92683
Rwq,,.,tats Farm General insurance Company.i 25151
I�jt ,SUREK a � i
_... y.-�
IN3VRED
THERESAKASPRZYK
INSUR€A C: _
DBA TERRASTAR MEDIA
INSURERD:
INSURER E; _.._..._ _
1380 JASPERSON WAY
WESTMINSTER, CA 92663
1 INSURERF�
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 VATH RESPECT TO MICH 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 SHOVuN MAYHAVE BEEN REDUCtO BYPADCLARKS.
POLICYEF€ POLM; P� ..m
TYpa tlPIHSURANCE 1. POLICY NUM BA - M. M tOOti LIMITS
ACCORDANCE WITH THE POLICY PROVISIONS.
CDM MERCIALOENERALUABIUTY
AunmRUEG f;PRP.3EMTA71
Costa Mesa, CA 92626 /I I
r l
EACH OCCURAErICE 51,000:000
�fj
ffilftAGETC, aEng __...
CiAIldSJAAi-`E �hl c7r/,'AIR
PRETAISES tEa nccuaetceJ, S ..
MEOEXP PIP $
92 -CF -N649 -5G
0712372017
0712312018 PERSO &, AOV INJURY 3
5 DiiQD __
GEN1 AOOREOATTE LIMIT APPLIES, PER
POLICY I 3�a 0 L
PRODUCTS -COMPIOP AGO sr000aD00
d7 ER
s
AUYOAtORFLP LU,81iIrY
COMRINEDN SINGE LN11 1 3
AHYAUTa
xxxxxx
BODI4YIN1URY(PwpNsuni f
TINNED 5CHEDItLEU
BODILY INJURY.tPerSGCWem] 1
A17Ci13i1MLY ARDS
'NON.ORNED
PROPERTY DAMAGE 1
;AUTO&Q'ti-v `AUTp$ONLY
(.FAL—we14Pnll
(
UMDREUA tike tlCC R
tADH'OCCURRENCII E
Y_ _
AG„ W.TE Ir
E%Ce35 L4ia 1"CLAIMS-MADE
XXXXXX
r—
DED RETENTIONS
I`
1WARERSCOMPENSAIDON
f
1rLI AN
AND -EMPLOYERS UkiNtIrV-
YfN
ANYPRO-IROOMPAnTNERrEXECUTI4E
NIA
E,L:EACH ACCIDENT §
_- .-..—
EL_D(SER�E•eAEMPLOYE T__
O-FICEMW.MBER EXCLEDUD
(MriW.te+yNi NH)
:XXXxXX
PTei,IPTIDauhl�
dESCRIPIW Ox OPERATInNSgetrx
E.L IRSEASE-POI-ICY LA4r L
I
DESCRIPTION DF dPERAT1ONSfLOCATIONS) VEHICLES IACORD VN,AAtlAlooA RiNo,oi, SdMdule,MAY IH mnmzhedlf mora SPecs Is nmUIRO)
Costa Mesa Sanitary District thea elected and appointed officials. agents, officers, volunteers, and employees listed as Additional Insured
Pursuant to attached endorseinient.
f:GGTCfI+ATL. 11 RCC, r:CANCFI. I. ATIr1N
01908-2076 A'y91RD CORPORATION. All rights reserved.
ACORD 25 (2016103) The ACORD name and logo are registered marks of ACORD
KMAa4 t?20<9.rT an.)DaDIa
SHOULD ANY OF THE ABOVE DESCRIBED. POLICIES BE CANCELLED BEFORE
THE 6XPIRATKIN DATE THEREOF, NOTICE WILL BE DELIVERED IN
Costa Mesa Sanitary District
ACCORDANCE WITH THE POLICY PROVISIONS.
290 Paularin°AvenueI�bl
AunmRUEG f;PRP.3EMTA71
Costa Mesa, CA 92626 /I I
r l
01908-2076 A'y91RD CORPORATION. All rights reserved.
ACORD 25 (2016103) The ACORD name and logo are registered marks of ACORD
KMAa4 t?20<9.rT an.)DaDIa
POLICY NUMBER: 92 -CF -N648 -5G
COMMERCIAL GENERAL LIABILITY
CG 20 12 07 98
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
ADDITIONAL INSURED -
STATE OR POLITICAL SUBDIVISIONS -PERMITS
This endorsement modifies insurance provided underthe following:
COMMERCIAL GENERAL LIABILITY COVERAGE PART
SCHEDULE
State Or Political Subdivision:
The Costa Mesa Sanitary District, It's elected and appointed officials, agents,
otficers, volunteers and employees are additional insureds.
(If no entry appears above, information required to complete this endorsement will be shown in the Declarations
as applicable to this endorsement.)
Section II - Who Is An Insured is amended to
include as an insured any state or political subdivi-
sion shown in the Schedule, subject to the following
provisions:
1. This insurance applies only with respect to op-
erations performed by you or on your behalf for
which the state or political subdivision has issued
a permit.
2. This insurance does not apply to
a. "Bodily injury," "property damage" or "per-
sonal and advertising injury" arising out of
operations performed for the state or munici-
pality, or
b. "Bodily injury' or "property damage" included
within the "products -completed operations
hazard".
Said policy shall not terminate, nor shall it be canceled nor the coverage reduced,
until thirty 00) days after written notice is given to the District.
Any other insurance maintained by the Costa Mesa Sanitary District shall be excess
and non-contributing with the insurance provided by this policy.
CG 20 12 07 98 Copyright, Insurance Services Office, Inc., 1997 Page 1 of 1 D