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Insurance - Second Chance Orange County - 2019-02-14^4t, LjK" �,,...--- CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DD/YYYY) 02/14/2019 THIS CERTIFICATE IS ISSUEDASA MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOTAFFIRMATIVELYOR 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(les) 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 CONTACT POLICY EXP (MM/DD/YYYY) NAME: Chuck Hyneman Chuck Hyneman PHONE FAX 18371-A Lemon Drive (A/C, NO, EXT): 714-777-9823 (A/C, No): 714-777-9898 E-MAIL Yorba Linda, CA 92886 EACH OCCURRENCE $ 1,000,00 ADDRESS: INSURER(S)AFFORDING COVERAGE NAIC# CLAIMS -MADE OCCUR INSURED INSURERA: United States Liability Insurance Company/ 25895 Second Chance Orange County 290 Paularino Avenue INSURER B: State Fund INSURER C: INSURER D: Costa Mesa, CA 92628 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THATTHE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAME ABOVE FOR THE POLICY PERIOD INDICATED, NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECTTO 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 ADDTL INSD SUBR WVD POLICY NUMBER POLICY EFF (MM/DD/YYYY) POLICY EXP (MM/DD/YYYY) LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,00 CLAIMS -MADE OCCUR DAMAGE TO RENTED $ PREMISES (Ea Occurrence) 100,000 MED EXP (Anyone person) $ 5,00 PERSONAL&ADV INJURY $ 1,000,000 A Y Y NPP1578341A 02/04/2019 09/14/2019 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 X POLICY a PROJECT ❑ LOC PRODUCTS -COMP/OPAGG $ Included $ OTHER: AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ 1,000,000 (Ea accident) BODILY INJURY (Per person) $ ANYAUTO BODILY INJURY(Per accident) $ A OWNEDAUTOSSCHEDULED AUTOS NPP1578341A 02/04/2019 09/14/2019 PROPERTY DAMAGE $ (Per accident) X HIRED AUTOS X NON -OWNED ONLY AUTOS ONLY $ UMBRELLA LIAR —d OCCUR EACH OCCURRENCE $ EXCESS LIAR CLAIMS -MADE AGGREGATE $ DED RETENTION $ $ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY X1 PER STATUTE OTHER $ B ANY PROPRIETOR/PARTNER/ Y/N EXECUTIVE OFFICER/MEMBER EXCLUDED? (Mandatory in NH) N/A 9226837-2018 02/04/2019 03/01/2020 E.L. EACH ACCIDENT $ 1,000,000 E.L. DISEASE - EA EMPLOYEE 1,000,000 E.L. DISEASE - POUCYLIMIT $ 1,000,000 If yes, describe under DESCRIPTION OF OPERATIONS below $1,000,000 Each claim A Professional E8�0 NPP1578341A 02/04/2019 09/14/2019 $2,000,000 Aggregate DESCRIPTION OFOPERATIONS/LOCATIONS/VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space Is required) Additional Insured: Costa Mesa Sanitary District, its elected and appointed officials, agents, officers, volunteers and employees "Said policy should not terminate, nor shall it be canceled nor the coverage reduced, until thirty (30) days after written notice is given to the named insured. Location: 290 Paularino Avenue Costa Mesa, CA 92628 CERTIFICATE HOLDER CANCELLATION Costa Mesa Sanitary District SHOULDANYOFTHE OVE SCRIBEDPOLICI B CELLEDBEFORETHEEXPTRATION 290 Paularino Avenue �+�� `� DATE THEREOF, NOTI WILL , ELIVE IN O�2 ITHTHE t Y ROVISIONS. Costa Mesa AUTHORIZED REPRESE ATr CA 9962R ACORD 25 (2016/03) 31-1769 11-15 ©1988-2015 ACORD CORPORATION. All Rights Reserved The ACORD name and logo are registered marks of ACORD UNITED STATES LIABILITY INSURANCE GROUP WAYNE, PENNSYLVANIA This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE FORM Primary And Non -Contributory - Written Contract Name of Person or Organization: Effective Date: 02/07/201912-.01 AM COSTA MESA SANITARY DISTRICT, IT'S DIRECTORS, OFFICIALS, OFFICERS, EMPLOYEES, AGENTS AND VOLUNTEERS BUT ONLY WHERE REQUIRED TO BE ADDED AS AN ADDITIONAL INSURED UNDER WRITTEN CONIRACT(S), WRITTEN PERMITS) OR WRITTEN AGREENIENT(S). 290 PAULARINO AVENUE COSTA MESA, CA 92626 (If no entry appears above, the information required to complete this endorsement will be shown in the Declarations as applicable to this endorsement) SECTION IV - COMMERCIAL GENERAL LIABILITY CONDITIONS, Paragraph 4. OTHER INSURANCE, a. Primary Insurance is amended with the addition of the following: The coverage afforded by this policy to the person(s) or organization(s) listed above is primary and non- contributory if: 1. This insurance is required to be primary and non-contributory under a written contract; and 2. The loss to be covered occurs on or after the effective date of the written contract, and 3. The loss to be covered resulted solely and exclusively from your ongoing acts or omissions or the ongoing acts or omissions of those acting on your behalf in performing "your work" under a written contract referred to above. 4. The person(s) or organization(s) is an additional insured under this policy. However, the coverage provided by this endorsement does not apply to any coverage provided for an "auto" on a "non -owned auto", "hired auto", uninsured motorists coverage, underinsured motorists coverage, personal injury protection, property protection or similar no-fault coverage by whatever name called and/or an "auto" coverage of any type. SECTION V - DEFINITIONS is hereby amended by the addition of the following: "Hired auto" means any "auto" you lease, hire, rent or borrow. This does not include any "auto" you lease for a period of more than thirty (30) consecutive days nor does it include any "auto" you lease, hire, rent or borrow from any of your "employees", your partner or your "executive officers" or members of their household. "Non -owned auto" means any "auto" you do not own, lease, hire, rent or borrow which is used in connection with your business. However, if you are a partnership, a "non -owned auto" does not include any "auto" owned by any partner. All other terms and conditions of this policy remain unchanged. This endorsement is a part of your policy and takes effect on the effective date of your policy unless another effective date is shown. L 776 (10-13) Page 3 of 4 POLICY NUMBER: NPPI678341A COMMERCIAL GENERAL LIABILITY CG 20 1104 13 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - MANAGERS OR LESSORS OF PREMISES This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Name of Person(s) Or Organization(s) (Additional Insured): Effective Date: 02/0712019 12:01 AM COSTA MESA SANITARY DISTRICT, ITS DIRECTORS, OFFICIALS, OFFICERS, EMPLOYEES, AGENTS AND VOLUNTEERS 290 PAULARINO AVENUE COSTA MESA, CA 92626 Designation of Premises (Part Leased To You): 290 PAULARINO AVENUE COSTA MESA, CA 92626 Additional Premium: $ Information required to complete this Schedule, if not shown above, will be shown in the Declarations. A. Section 11 -Who is An Insured is amended to include as an additional insured the person(s) or organization(s) shown in the Schedule, but only with respect to liability arising out of the ownership, maintenance or use of that part of the premises leased to you and shown in the Schedule and subject to the following additional exclusions: This insurance does not apply to: 1.Any "occurrence" which takes place after you cease to be a tenant in that premises. 2. Structural alterations, new construction or demolition operations performed by or on behalf of the person (s) or organization(s) shown in the Schedule. However: 1.The insurance afforded to such additional insured only applies to the extent permitted by law; and 2. If coverage provided to the additional insured is required by a contract or agreement, the insurance afforded to such 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 respect to the insurance afforded to these additional insureds, the following is added to Section III - Limits Of Insurance: If coverage provided to the additional insured is required by a contract or agreement, the most we will pay on behalf of the additional insured is the amout of insurance: I. Required by the contract or agreement; or 2.Available under the applicable Limits of Insurance shown in the Declarations; whichever is less. This endorsement shall not increase the applicable Limits of Insurance shown in the Declarations. CG 20 110413 0 Insurance Services Office, Inc., 2012 Page 1 Of 1