Loading...
Insurance - Robotic Sewer Solutions - 2018-11-20r1 0 ACOREP CERTIFICATE OF .LIABILITY INSURANCE �,,.,�„�� DATE (MMDD/YYYY) 11 /20/2018 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 Bolton & Com any CONTACT NAME: PHONE FAX A/C. No. Ext): 626 799-7000 A/C No : 626 583-2117 3475 E. Foothill Blvd., Suite 100 Pasadena, CA 91107 E-MAIL ADDRESS: INSURERS AFFORDING COVERAGE NAIC # INSURER A: James River Insurance Company 12203 www.boltonco.com 0008309 INSURED Robotic Sewer Solutions, Inc. 1111 Foothill Boulevard, Suite B INSURER B : StarStone Specialty Insurance Company 44776 lNsuRERc: State Compensation Insurance Fund INSURER D: La Canada, CA 91011 INSURER E: INSURER F: CnVERAGES CERTIFICATE NUMBER: ARARARC17 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 SUER POLICY NUMBER MM DDPOLICY EFF MMDD EXP LIMITS A �/ COMMERCIAL GENERAL LIABILITY ✓ 000506278 11/22/2018 11/22/2019 EACH OCCURRENCE $1,000,000 , � � CLAIMS -MADE 1 I OCCUR DAMAGE TO RENTED PREMISES Ea occurrence $ 50,000 ✓ Per Project Aggregate MED EXP (Any one person) $ 1,000 Capped at $5,000,000 ✓ PERSONAL & ADV INJURY 1 $ 1,000,000 GEN'L GENERAL AGGREGATE $ 2,000,000 AGGREGATE LIMIT APPLIES PER: C RO PROLICY E ECT LOC PRODUCTS - COMP/OP AGG $ 2,000,000 OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ Ea accident ANY AUTO BODILY INJURY (Per person) $ OWNED I SCHEDULED BODILY INJURY (Per accident) $ AUTOS ONLY AUTOS HIRED NON -OWNED PROPERTY DAMAGE $ AUTOS ONLY AUTOS ONLY Per accident $ B UMBRELLA LIAB �/ OCCUR 87446H185AL1 11/22/2018 11/22/2019 EACH OCCURRENCE $4,000,000 v/ EXCESS LIAB CLAIMS -MADE AGGREGATE $4,000,000 DED ✓ RETENTION $0 $ C WORKERS COMPENSATION 1980264 11/22/2018 11/22/2019 ✓ STATUTE EORH AND EMPLOYERS' LIABILITY Y / N ANYPROPRIETOR/PARTNER/EXECUTIVE j E.L. EACH ACCIDENT $ $1,000,000 OFFICER/MEMBEREXCLUDED? E N /A (Mandatory in NH) ( ( E.L. DISEASE - EA EMPLOYEE $ 1 OOO OOO If yes, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT $ $1,000,000 I i I DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) GL Additional Insured applies per CG20120509 attached. Additional Insured(s): The Costa Mesa Sanitary District, it's elected and appointed officials, agents, officers, volunteers and employees. The Certificate of Insurance is subject to policy terms, conditions, limitations and exclusions. ly;4:I112Le1_\1:0:Lei 141Ja: MK -I , I► CyaI1W,1ILei Z Costa Mesa Sanitary District SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE rY THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 290 Paularino Avenue ACCORDANCE WITH THE POLICY PROVISIONS. Costa Mesa CA 92626 � `� f,�/it • 1��.�{/ (� AUTHORIZED REPRESENTATIVE David Kuo ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD 45486597 1 ROBOSEW-01 1 18-19 GL, XS & WC, 18-19 1 Nancy Cadwallader 1 11/20/2018 10:45:19 AM (PST) I Page 1 of 2 POLICY NUMBER: 000506278 COMMERCIAL GENERAL LIABILITY CG 20 12 05 09 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - STATE OR GOVERNMENTAL AGENCY OR SUBDIVISION OR POLITICAL SUBDIVISION - PERMITS OR AUTHORIZATIONS This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE State Or Governmental Agency Or Subdivision Or Political Subdivision: The Costa Mesa Sanitary District, it's elected and appointed officials, agents, officers, volunteers and employees Information required to complete this Schedule, if not shown above, will be shown in the Declarations. Section II — Who Is An Insured is amended to in- clude as an insured any state or governmental agen- cy or subdivision or political subdivision shown in the Schedule, subject to the following provisions: 1. This insurance applies only with respect to opera- tions performed by you or on your behalf for which the state or governmental agency or subdivision or political subdivision has issued a permit or author- ization. CG 2012 05 09 2. This insurance does not apply to: a. "Bodily injury", "property damage" or "personal and advertising injury" arising out of operations performed for the federal government, state or municipality; or b. "Bodily injury" or "property damage" included within the "products -completed operations hazard". © Insurance Services Office, Inc., 2008 45486597 1 ROBOSEW-01 1 18-19 GL, XS & WC, 18-19 1 Nancy Cadwallader 1 11/20/2018 10:45:19 AM (PST) I Page 2 of 2 Page 1 of 1