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Insurance - Golden Bell Products Inc. 2017-10-03�`►� �® CERTIFICATE OF LIABILITY INSURANCE DATE IMM DDYYYY) 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. - Ringsburg PO Box 67 CONTACT NAME: Jeanette Heinriche PHONE FA% C o Est: (559) 897-2975 AIC No: (559) 897-4070 E-MAIL Ringsburg CA 93631 ADDRESS: INSURERS AFFORDING COVERAGE NAIC# INSURER A: Evanston Insurance Company/ 35378 INSURED (714) 630-3861 Golden Bell Products, Inc. INSURER B: OCCUR INSURER C: INSURERD: P.O. Box 366 INSURER E: Atwood CA 92811 INSURER F : MED EXP (Any one person) $ 5,000 COVERAGES CERTIFICATE NUMBER: Cert ID 28223 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 ADDL D SUER WVD POLICY NUMBER POLICY EFF MM/DD/YYYY POLICY EXP MMMD LIMITS A X COMMERCIAL GENERALLIABILIW EACH OCCURRENCE $ 1,000,000 OCCUR MKLV5ENV100373 10/25/201710/25/2018 RINT1CLAIMS-MADE =IME SOL. occuu ante $ 50,000 MED EXP (Any one person) $ 5,000 X CPL X 10,000 SIR PERSONAL 8 ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERALAGGREGATE $ 2,000,000 IRI - POLICY � ❑ LOC X ECT ECT J PRODUCTS - COMPIOP AGG $ 2,000,000 $ OTHER: AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ Ea accident BODILY I NJ URY(Per person) $ ANY AUTO BODILY INJURY (Per accident) $ ALL OWNED SCHEDULED AUTOS AUTOS PROPERTYDAMAGE $ Per accident NON -OWNED HIRED AUTOS AUTOS A UMBRELLA LIAB X OCCUR MKLV5EPX100100 10/25/2017 10/25/2018 EACH OCCURRENCE $ 2,000,000 AGGREGATE $ 2,000,000 X EXCESS UAB CLAIMS -MADE DED I X I RETENTION$ 10,000 $ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY YIN ANY PROPRIETORIPARTNEREXECUTIVE SPTERTH- ER EL EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? ❑ NIA (Mandatory in NH) E.L. DISEASE- EA EMPLOYE $ DISEASE -POLICY LIMIT $ If yes, describe under DESCRIPTION OF OPERATIONS belowE.L. A Cont. Pollution Liab. MKLV5ENV100373 10/25/2017 10/25/2018$25,000 SIR $ 1,000,000 A Environ. Impairment Liab. MKLV5ENV100373 10/25/2017 10/25/2018$25,000 SIR $ 1,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS I 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. CERTIFICATE HOLDER Ta P.f'FP.lvFl) CANCELLATION Z017 OCT O 9 Z017 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Costa Mesa Sanitary District 290 Paularino Avenue Costa Mesa S,nitarLIYr�aD1st[4Ct Costa Mesa CA 92626 AUTHORIZED REPRESENTATIVE 01988-2014 ACORD CORPORATION. All rights reserved. ACORD 25 (2014101) The ACORD name and logo are registered marks of ACORD CERTIFICATE COVERAGES OVERFLOW PRODUCER INSURED Van Beurden Ins. Serv, Inc. - Ringsburg Golden Bell Products, Inc. PO Box 67 P.O. Box 366 Ringsburg CA 93631 Atwood CA 92811 CONTACT NAME: PHONE (A/C, No, Ext): PHONE (A/C, No, Ext): Jeanette Heinrichs (559) 897-2975 1 (714) 630-3861 ADDITIONAL COVERAGES CERTIFICATE NUMBER: Cert ID 28223 REVISION NUMBER: DATE (MM/DD/YYYY) 10/03/2017 INSR LTR TYPE OF INSURANCE ADDL INSR SUBR W D POLICY NUMBER POLICYEFF (MM/DD/YYYY) POLICY EXP (MM/DD/YYY9) "MOS A Incid.Prof.Services Liab. MRLV5MW100373 10/25/2017 10/25/2018 $ 1,000,000 $ $ Certificate Coverages Overflow (11/2010) ACORD CERTIFICATE OF LIABILITY INSURANCE DATE(FAMWWYYYY) 101OV2017 PRODUCER CalCoast 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. _. PoUCYNUMBER POLICY EFFECENE POLICY EXPULtTHkI INSURERS AFFORDING COVERAGE INSURED Golden Bell Products Inc- _ INSURER a Mercury Casually Company _NAIC PO BOX 366 _ INSURER s: State Compensation Ins. Fund _ _ __ _ ATWOOD CA 92811 INSURER c. INSURER n .... ..-- INSURERE: ,_..—. ----"— S CO 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 wHtCH THIS CERTIFlCATE 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 MAYHAVE SEEN REDUCED BY PAID CLAIMS. NSR- hLm Sm TYPEOFINSURANCE _. PoUCYNUMBER POLICY EFFECENE POLICY EXPULtTHkI -........ ._-..- L"A"S GENERAL UABILFIY EACHOCCURRENCE g COW&RCW GENERALLIABILITY CLAIMS MADE F� OCCUR DAMAGE TO RENTED pAc➢EXP IFrrcme�r�x: ----"— S $ -_—_ PERSONAL&ADV INJURYGENERALAGGREGATB 3 GEN71-OREC'ATE POLICY UMITAPPUESPER. PRO- n LOC PRODUCTS -COMP _ AUTOMOBILE LIABILITY A Y X ANY AUTO CCADOOIS40 10.14- 2017 10.14-2018 COMBINED SINGLE LIMIT (Ea �6�Ii ;1,000,000- ALL OWNED AUTOS X 6CHEDULEp N_ROS BODILY INJURYtpM Ar,yoAl S X HIREDAUTOS X NON-O'J FEO AUTOS BODILY INJURY ,Per.m Nl S PROPERTY DAMAGE IP@r a[ Mj 3 I ,GARAGE LIABILITY - AUTOONLY•EAACCIDENi S EA ACC --__.... 3 ANY AUTO 3 - ALDO ONLY AUrO ONLY AGG MBE3ILITY (EACHOCCURRENCE 3 AGGREGATE $ C:AIMSMADE r1=11T:NnES 3 B VNIRRERSOOMPENSATLONANO ENPLOYER IETORZOrY AF FICE"156 ;oR MLIJERroO:curRrE OFy/FU5sIC.ERMIEMBER EXCLUOEOT 3PECI�P�R�Ov11A1SIONS 7714034 110-04-207 ! 110.04.2016 X WC STATU- pTH_ $ 1,000,000 EL EACH ACCIDENT E.LDISEASE-EA EM.�I.OYE 1000,000 . EL DISEASE - POLICY LIMB $1,000000 !. I Eekv: OTHER OESCMMON OF OPERATIONS, LOCATIONS I VEHICLES I EXCLUSIONS ADOEO BY ENOORSEMENTI SPECM PROVIBION5 The Costa Mesa Sanitary District, It's elected and appointed officials, officers, agents, and employees are additional Naured's. we have Requested that the Cerfifieate Holder be listed as Additional Insured. 10 day notice of cancellation for nan-payment of premium. Costa Mesa Sanitary District 628 West 19th Street Costa Mesa, CA. 92627 SHOOLUANYOFTHEASUVEDESCRISEOPOLICIES 13ECANCELLEDMFORE THEEXPIRATION DATE THEREOF. THE ISSUING INSURER ILL ENDEAVOR TO MAIL 30 DAYS WRITTEN NOTICETOTHE FIC TE LDER LMEDTOTHE LEFT, BUT FALLURETOOOSO SHALL IMPOSE NO cau TION L dIJ t,P ANY HIND UPON THE INSURER, ITS AGENTS OR P"In T AUTH REP 949576.1534 ---1-11 "1 F 0 ACORD CORPORATION 198E CERTIFICATE COVERAGES OVERFLOW Van Beurden Ias. 5erv, Ioo. - Eisgsbu=g PO Bax 67 Kiagsburg CA 93631 Golden. Heli Products, Inc. P.O. Box 366 CONTACT NA I PHONE (A/C, No, Ext): I PHONE (A/C, No, Ext}: aeanotte Heinrichs I! (5591 H97-2975 (714) 630-3861 ADDITIONAL COVERAGES CERTIFICATE NUMRMO rr Tn 7A11A actnanw wiEnArece. 10/03/2017 Q ITP: TYPEOFfNSUMA ADDt MR 51100. =Da I PG(I[YNUMDER Fo=EFF mmla /YYYl1 PaMEYV IM/DD/YYM txviS A Incid. Pro£. Servicas mob. MKLVSZM00373 10/25/2017 10/25/2018 $ 1,000,000 $ $ S 5 $ r $ 5 5 . � 5 5 S S $ $ $ $ S Certificate Coverages Overflow (11/2010) Pace 2 of 2 COMMERCM GENMAL LIABILITY POLICY NUMBEir kKLV5ENV100373 di" MOW EVANSTON INSURANCE COMPANY THIS ENDORSEMENT CHANGES THE POLICY. PJ-9ASE READ IT CAREFULLY. BLANKET ADDITIONAL INSURED - PRIMARY AND NON-CONTRIBUTORY - OWNERS, LMEES OR CONTRACTORS This endorsement modifies Insurance provided underthe followkv. COMMERCIAL GENERAL L"ILITY COVERAGE FORM A. Section It — Who is An Insured is amended to include as an additional insured any person(s) or organlzation(s) to whom the Insured agrees to provide additional Inaurod status on a primary and non-cohtrlbutory basis In a written contract, provided such written oontryaat Is sighed by both parties and executed prior to the oommencement of operations, but only with respect to Ilablltty for "bodily injury", property damage' or "personal and advertising injury" caused, in whole or In part, by: 1, Your acts or omissions, or 2. The acts or omissions of those acting on your behalf; In the performance ofymw 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 WIIt not be broader then that which you are required by the contract or agreement to provide for such additional Insured. E� With respectto the Insurance afforded to these additional Insureds, the following addltlonat exaluslons apply. This Ihouranoe does not apply to 'bodily Injury", "property damage, or "personal and advertising lnjury" aoourring after: 1. All work an the project (other than servloe, mainterranos or repairs) to be performed by or on behalf of the additional Insured at the location of the oovered operations, including materials, parts or equipment furnished In connection with such work, has been completed; or 2, That portion of "your work" out of which the ft" or damage arlses has been put to Its Intended use by any person or organlzatbn other than another contractor or subcontractor engaged In performing operations for a principal as a part of the same project, C. Whir nespact to the Insurance afforded to these additional insureds, the following is added to Section Ili — Limits Of Insuranoel The most we will pay on behalf of the additional insured Is the amount of Insurance: 1, Required byte contractor agreement; or ,2.. Available under the applicable Limits Of insurance shown fn the Declarations; - whtohever is less. This endorsement will not Increase the applicable LJmlts Of Insuranoe Shawn In the Declaration). MROL 1943 9816 Includes copyrighted material of insurance Sprvioes Office, Inc, Page 1 of 2 with Its permission, 0, With respect to the coverage provided by this endorsements the following Is added to Paragraph 4. other insurance under Section IV— Commerclai General Liability Conditions: Primary And Noncontributory Insurance This Insurance is primary to and will not seek oontrIbution from any other Insurance available to any pdrsoh(s) or organiration(s),qualVrig as an dddltlondl Insured by this endorsement provided that; (1) The additional insured is a Named Insured under such other insurance; and (2) You have agreed In writing In a contract or agreement that this Insurance would be primary and would not seek contrlbtAon from any otherinsuranoe available to the additlonal Insured, Ail other terms and conditions remain unchanged, MEGL ISO 05 40 Includes copyrighted material of Insurance Services ottioe, Ina„ Page 2 of 2 with Its permission, . POLICY NUMBER: MKLV5ENV100373 COMMERCIAL GENERAL LIABILITY G620 3-104 13 THIS ENDORSEMENT CHANGES THE POLICY, PLEASE READ IT CAHEPULLY, ADDITIONAL INSURED -- OWNERS, LESSEES OR CONTRACTORS - COMPLETED OPERATIONS This endorsement modlfles Insurance provided under the following: COMME?RCiAL GENERAL LIABILITY COVERAGE PART PRODUCTSICOMPLETED OPE=RATIONS LIABILITY COVERAGE PART SCHEDULE Name Of Additional Insured Person(s) Or Or anizotlon s Location And Description Of Gam feted Operations Any-person(s) or organlzatfon(s) to whom the Insured agrees to provide Addit1onal Insured status In a written contraot signed by both parties and 100outod prior to the commencement of operations NotAppiicable Information require to complete this Schedule if not shown above Wil be shcwn in the Dadaratlp A. Section it — Who Is An Insured is amended to Include as an additional insured the persons) or organlzatlon(s) ahown in the Schedule, but only with raspeot to liability for "bodily lNury" or "propartydamage°oaused, 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 "produots-completed operations hazard". However. 1, The insurance afforded to such additional Insured only applies to the extent permitted bylaw; and 2. if coverage provided to the oddldonal Insured is required by a oontraot or agreement, the Insurance afforded to suoh 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 rsspect to the insuranoa offotded to these additional Insureds, the foliowtng Is added to Section III Limits Of Insurance, If coverage provided to the additional Insured Is required by a contract or agreemen 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 Dadarations; whichever is toss, This endorsement shall not Increase the applicable Lfmks of Insurance shown in the Declarations. CG 20 310413 0 insurance Services Offloe, Inc„ 2012 Page 1 of 1 COMMERCIAL GENERAL LIASILirY POLICY NDMMERr MKLV5ENV100373 POUCYNUMBER: 16PKOWE00626 gig E'VANSTON INSURANCE COMPANY THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. BLANKET WAIVER OF TRANSFER OF RIGHTS OF RECOVERY AGAINST OTHERS TO US This endorsement modifies Insurance provided under the following: COMMERCIAL. GENERAL. LIASIUTY COVERAGE FORM SCHEDULE Name Of Person Or Organization: Any persons) or organization(a) with whom the Named Insured agrees, in a written contract executed prior to the "ocourrence", to waive rights of recovery AddittanalPremium: $Included The following Is added to Condition 8, Transfer Of Rights Of Recovery Against Others To Us under Section IV — Commercial general Liability Conditions: We waive_ any right of recovery we may have against any person or organization shown In the Schedule of chis endorsement, This waiver applies onlyto the person or organization shown In the Schedule of this endorsement All other terms and conditions remain unchanged. MEGL, 02411-0105 16 thcludea copyrighted material of insurance Services Office, Inc,, Pagel of 1 with Its pormlWon,