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Insurance - Golden Bell Products, Inc. 2017-10-03/ I a ACORD CERTIFICATE OF LIABILITY INSURANCE 11%.�' DATE(MMIDD/YYYY) 10/03/2017 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 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 endomement(s). PRODUCER Van Beurden Ins. Serv, Inc. - &ingsburg PO Box 67 CONTACT NAME: Jeanette Heinr'ichs PHONE I FAX (559) 897-2975 - ac No): (559) 897-4070 E-MAIL X COMMERCIAL GENERAL LIABILITY Kingsburg CA 93631 ADDRESS: INSURER(S) AFFORDING COVERAGE NAIC# INSURER A: Evanston Insurance COmpan X 35378 INSURED (714) 630-3861 INSURER B: Golden Bell Products, Inc. INSURER C : INSURERD: P.O. BOX 366 INSURER E: Atwood CA 92811 INSURER F: X CPL r.nVFRAr:FR CFRTIFICATF NIIMRFR- Cert TD 28223 REVISION NHMRER: 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 ADDL INSD SUBR IWO POLICYNUMBER POLICY EFF MM/DD/YYYY POLICY EXP MM/DO LIMITS A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 � OCCUR MKLV5ENV100373 10/25/2017 10/25/2018 DAMACLAIMS-MADE PREMISES Eaoccunence $ 50,000 PREMISES Ea occurrence) MED EXP (Any one person) $ 5,000 X CPL X 10,000 SIR PERSONAL B ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER. GENERAL AGGREGATE $ 2,000,000 X POLICY 0PRJECT O- 11 LOC PRODUCTS -COMPIOP AGG $ 2,000,000 $ OTHER. AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ Ea accident BODILY INJURY (Per person) $ ANY AUTO BODILY INJURY (Per accident) $ ALL OWNED SCHEDULED AUTOS AUTOS Perraccment AMAGE $ PROPERTYHIRED AUTOS AUTOS NON -OWNED A UMBRELLA LIAB X OCCUR MKLV5EPX100100 10/25/2017 10/25/2018 EACH OCCURRENCE $ 2,000,000 AGGREGATE $ 2,000,000 X EXCESS DAB CLAIMS -MADE DED I X RETENTION$ 10,000 $ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY YIN PER OTH- STATUTE ER. ANY ECUTIVE E.L. EACH ACCIDENT $ OFFICEWMEMBER/EXCLUDED r_1N/A (Mandatory in NH) E.L. DISEASE - EA EMPLOYE $ If yes, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE -POLICY LIMIT $ A Cont. Pollution Liab. MKLV5ENV100373 10/25/2017 10/25/2018$25,000 SIR $ 1,000,000 A Environ. Impairment Liab, MXLVS8NV100373 10/25/2017 10/25/2018$25,000 SIR $ 1,000,000 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) Re: Manhole spraying for roaches at various city locations. It is agreed that the Costa Mesa Sanitary District, its elected and appointed officials, officers, agents, and employees are named as additional insureds as respects to General Liability per attached additional insured form only when required by written contract. 7]1i Um sal -111 L -A0 �/ SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE QCT O 9 2017 THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Costa Mesa Sanitary District ACCORDANCE WITH THE POLICY PROVISIONS. 290 Paularino Avenue Costa Mesa Sanitary District AUTHORIZED RIREPRESENTATIVE Costa Mesa CA 92626 ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25 (2014/01) The ACORD name and logo are registered marks of ACORD ACORDM CERTIFICATE OF LIABILITY INSURANCE DATE(MMTDDMWn 1010 412 01 7 PRODUCER CaiCoast Insurance Agency P.O. Box 1070 Los Alamitos, CA. 90720 - THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. hYSR -LM 4001 SM __ _ INSURERS AFFORDING COVERAGE 4 IRSURm Golden Bel[ Products Inc. PO BOX 366 _ _ INSURERA, MQtCU Cae08 Co n _NAIC IwuRERO_ State Compensation fns. Fund GENERAL LMBUJIY ATWOOD CA 92811 INSURFRc, - IN_URER D. _... INSURER E: 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. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. hYSR -LM 4001 SM 628 West 19th Street POLICY NUMBER MUCYEFFECITVE POLtCYEX rexnON —..... Loam REPRES T GENERAL LMBUJIY 949515-1534 EACH OCCURRENCE S COMMERCW. GENERAL LIABIL Tf ----- DAMAGE TO RENTED CEWJ:MADE r-1 OCCUR S T9 EXP LAELme PERSONA, S ADV INJURY $ GENFRPIAGGRECATE S GENLAGGREGATE LINIITAPPLIES PER'. PRODUCTS-CgIIOPAGG $ POLICY PRO- ECT LOC - AUTOMOER4 UAMUTY A Y X ANY AUTO COA0001840 10-14-2017 1044-2018 COMBIN (EE&a dwfy INCLE LIMIT 51,000,000 ALL OWNED AUTOS - X BODILY INJURY SCHEDULEDALROS (Per perwn) 6 X HIREDAUTOS X BODILY INJURY-�--�- 5 NON-0WT�p AUTpS (Pen eetldeMt PROPERTY DAMAGE 5 I (Per ecddeml GARAGE L . MSILTtt ( AUT ONLY-EAACCOENT S __-__... ANYAUTO OTHERTHAN EAACCLI 6 ..._ AUTO ONLY AGO 5 EXCESSRIMBRELLAUARRITY EACH OCCURRENCE 5 AGGREGATE s OCCUR El CIAIMSMA)E -- DEDUCTIBLE $ RETENTION 8 _ --- 6 WORKERSCOMP SATIOMANO f X wC 8iRTU- 0TH_ B EMPLOYERS' LIABILITY I ANY PROPRIETOR ARTNEWEXECUTIVE 10.04-2017 10-04-2018 -- ET.. EacxacclDENr s1,000,000 _- RaT XCLUOED'l E.LDMEASE-EAEMPLWE 1600000 I1T14034 If.. Ifees. deaabe ender .der _ E.L. 015EASE- POLICY 1 MIT $1,000,600 SPECT PROWISIONSbdi i I OTHER DESCRIPTION OF OPERATIONS T LWATONS i VEHICLES t EXCLUSIONS ADOED BY ENDORSEMENT/SPECIAL PROVISIONS The Costa Mesa Sanitary District, It's elected and appointed officials, officers, agents, and employees are additional trisured's. we have Requested that the Certificate Holder be listed as Additional Insured, 10 day notice of cancellation for non-paryment of premium. - ea,r.nvw�n CANCELLATION — `" L` '..' v Q ACORD CORPORATION 1988 SROULDANYOFTRSA EDeSCROEDMUMESSFC CELLEDBEFORETHEEXPIRATON Costa Mesa Sanitary District DATE THEREOF, 30 THE ISSUING LNSURER WALL ENDEAVOR TO MAIL DAYS WRITTEN 628 West 19th Street NOTICETOTHE FIC TE ER WTOTHELFFT,aUTFULURETODOSOSHALL Costa Mesa, CA 92627 IMPOSE NO OBtt TON: L F ANY KIND UPON THE INSURER, ITS AOENTB OR REPRES T AUTHO REP 949515-1534 — `" L` '..' v Q ACORD CORPORATION 1988 CERTIFICATE COVERAGES OVERFLOW Van Seurdm ins. 8erv, lao. - &ingsburg PO Sass 67 8imguburg CA 93631 Jeanette Hai=iCh9 (559) 897-2975 Golden. Hell Prodveta, Iae. P.O. Box 366 Atwa d G 929 (714) 630-3861 ADDITIONAL COVERAGES CERTIFICATENUMBER:cart ID 23223 REVISION NUMBHL• 10/03/2017 Lu T OFIMMN= AOL IM S K ma I POIICYNUMwFR FOUC/EFF PAWMAYM FOUL w (m/w/nm fixiS A Incid.Pro£.Serviwee Liab. MMVSRM00373 10/25/2017 10/25/2018 $ E, 000,000 $ S S $ S 1 5 5 5 • S 5 5 S i 5 5 5 5 Certificate Coverages overflow (11/2010) Pace 2 of 2 COMMFRCfAL GENERAL LIABILITY POLICY NIWERr kKLV5ENV100373 di, EVANSTON INSURANCE COMPANY THIS ENDORSEMENT CHANCES THE POLICY. PLEASE REAL) IT CAREFULLY. BLANKET ADDITIONAL INSURED —PRIMARY AND NON•CONTRiBUTORY — OWNERS, LESSEES OR CONTRACTORS This endorsementmod►fies Insurance provided underthefollowing: COMMERCIAL GENERAL LIAOILITY COVERAGE FORM A. Section It — Who is An Insured is amended to include as an additional insured any parson(a) or organization(s) to whom the Insured agrees to provide additional insured status on h primary and non-contributory basis In a written contract, provided such wdtien oonttact is signed by both paroles and executed prior to the oommencoment of operations, but only with respect to liability for "bodlly Injury", property damage" or "personal and advertising injury" caused, In whole or In part, by: 1. Your acts or omisolon8; or 2. The acts or omissions of those acting on your behalf; In the performance of your ongoing operations for the additional insured. However, the insurance afforded to such additional insured: 1. Only applies to tho extant permitted by taw, and Z Will not be broader than that which you are required by the oonfract or agreement to provide for such additional Insured. Er Wtth respectto the Insurance afforded to these additional Insureds, the following additional exclusions apply: This Insurance does not apply to 'bodily injury", °properly damage°, or "personal and advertising injury" occurring atter. 1. All work on the project (other than seivloe, malntenanos or repairs) to be performed by a on behalf of the additional insured at the location of the covered operations, including materials, parts or equipment furnished In connection with such work, has bean ramploted; or 2, That portion of "your work' out of which the h>jury or damage arises has been put to Its Intended use by any person or cwgantzatlon other than another contractor or suboonttaotor engaged In performing operations for a principal as a part of the same project, C. With respact to the Insurance afforded t these additional Insureds, the following Is added to Section IIi — Limits Of lnsur&noet 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; - whiohever Is less, This endorsement wID not Increase the applicable omits Of Insuranoa shown In the Declarations. MEOL 1543 0818 Inoiudes copyrighted material of insurance Sarvioes Office, Inc, Page 1 of 2 with Its permisslom