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Insurance - Southern California Fleet Services, Inc. 2019-04-04A� D� CERTIFICATE OF LIABILITY INSURANCE DAT�(M 442019YY, 04l04t2019 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 endorsements). COMMERCIAL GENERAL LIABILITY CLAIMS MADE X OCCUR PRODUCER FEDERATED MUTUAL INSURANCE COMPANY HOME OFFICE: P.O, BOX 328 CONTACT NAME: CLIENT CONTACT CENTER PHONE NExt : 868-333-4949 FAX No): 507-446-4664 ADDRlEss: CLIENTCONTACTCENTER FEDINS.COM OWATONNA, MN 5500 INSURER(S) AFFORDING COVERAGE NAIC # INSURER A: FEDERATED MUTUAL INSURANCE COMPANY 13935 X INSURED 336-585-5 INSURER B: SOUTHERN CALIFORNIA FLEET SERVICES INC 2855 SAMPSON AVE INSURER C: INSURER D: CORONA, CA 92879-6126 INSURER E: AUTOMOBILE LIABILITY X ANY AUTO SCHE OWNED AUTOS ONLY AUTOSULED HIRED AUTOS ONLY NON OWNED AUTOS ONLY INSURER F: N COVERAGES CERTIFICATE NUMBER: 303 REVISION NUMBER: 1 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. ILT R TYPE OF INSURANCE DL SUBR WVDPOLICY NUMBER POLICY EFF MPOLICY EXP LIMITS A X COMMERCIAL GENERAL LIABILITY CLAIMS MADE X OCCUR Y N 9823225 03/0112019 03/01/2020 $1,000,000 EACH OCCURR;ED; DAMAGE T R $100,000 to X MED EXP (Any EXCLUDED PERSONAL & ADV INJURY $1,000,0W Cl.GE AGORE LIMIT APPLIES PER. POLICY rl JECT ❑ LOC OTHER: GENERAL AGGREGATE $2,000,000 PRODUCTS - COMPIOP AGO $2,000,000 A AUTOMOBILE LIABILITY X ANY AUTO SCHE OWNED AUTOS ONLY AUTOSULED HIRED AUTOS ONLY NON OWNED AUTOS ONLY N N 9823225 03/01/2019 03/01/2020 COMBINED SINGLE LIMIT $1,000,000 (Ea accidend BODILY INJURY (Per person) BODILY INJURY (Per accident) PROPERTY DAMAGE Ip Accident) A X UMBRELLA LIAB EXCESSLIAB X ri OCCUR CLAIMS -MADE N N 9823226 03/01/2019 03/01/2020 EACH OCCURRENCE $4,000,000 AGGREGATE $4,000,000 DED I I RETENTION WORKERS COMPENSATION AND EMPLOYERS' LIABILITYY/N ANY PROPRIETORIPARTNERIEXECUTIVE L OFFICERIMEMBER EXCLUDED? (Mandatory In NH) It yes, describe under DESCRIPTION OF OPERATIONS below N I A OTH- PER STATUTE ER E.L. EACH ACCIDENT E.L. DISEASE - EA EMPLOYEE E.I. DISEASE - POLICY LIMIT DESCRIPTION OF OPERATIONS i LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) SEE ATTACHED PACE CERTIFICATE HOLDER CANCELLATION 336-585-5 3031 COSTA MESA SANITARY DISTRICT 290 PAULARINO AVE SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN COSTA MESA, CA 92626-3314 ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE _ l���VVti/ ® 1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016103) The ACORD name and logo are registered marks of ACORD A1+C V�. �..•+r' AGENCY CUSTOMER ID: 336-585-5 LOC #: ADDITIONAL REMARKS SCHEDULE Page 1 of 1 AGENCY NAMEDINSURED FEDERATED MUTUAL INSURANCE COMPANY SOUTHERN CALIFORNIA FLEET SERVICES INC SAMPSON AVE CORONA, CA 92879-6126 POLI2855 NUMBER S SEE EE CERTIFICATE # 303.1 CARRIER NAIC CODE SEE CERTIFICATE # 303.1 EFFECTIVE DATE. SEE CERTIFICATE ## 303.1 nnrilTIAKIAI OCULLO VC THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, FORM NUMBER: 25 FORM TITLE: CERTIFICATE OF LIABILITY INSURANCE ADDITIONAL INSURED INCLUDES: COSTA MESA SANITARY DISTRICT, THEIR ELECTED AND APPOINTED OFFICIALS, AGENTS, OFFICERS, VOLUNTEERS AND EMPLOYEES THE CERTIFICATE HOLDER IS AN ADDITIONAL INSURED ON GENERAL LIABILITY SUBJECT TO THE CONDITIONS OF THE ADDITIONAL INSURED - OWNERS, LESSEES, OR CONTRACTORS - SCHEDULED PERSON OR ORGANIZATION ENDORSEMENT. INSURANCE PROVIDED BY THE GENERAL LIABILITY COVERAGE IS PRIMARY AND NONCONTRIBUTORY OVER OTHER INSURANCE. FOR REASONS OTHER THAN NON-PAYMENT OF PREMIUM, 30 DAYS NOTICE WILL BE PROVIDED TO THE CERTIFICATE HOLDER IN THE EVENT THAT THE ISSUING COMPANY CANCELS THE POLICY BEFORE THE EXPIRATION DATE OF THE POLICY. ACORD 101 (2008101) 0 2008 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD COMMERCIAL GENERAL LIABILITY CG 20 0104 13 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. PRIMARY AND NONCONTRIBUTORY - OTHER INSURANCE CONDITION This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE PART The following is added to the Other Insurance Condition and supersedes any provision to the contrary: Primary And Noncontributory Insurance This insurance is primary to and will not seek contribution from any other insurance available to an additional insured under your policy 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 contribution from any other insurance available to the additional insured. @ Insurance Services Office, Inc., 2012 Page 1 of 1 -- CG 20 0104 13 Policy Number: 9823225 Transaction Effective Date: 03-13-2019 POLICY NUMBER: 9823225 COMMERCIAL GENERAL LIABILITY CG 20 10 0413 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - OWNERS, LESSEES OR CONTRACTORS - SCHEDULED PERSON OR ORGANIZATION This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Name Of Additional Insured Person(s) Or Organizations: Location(s) Of Covered Operations COSTA MESA SANITARY DISTRICT See IL -F-40-0003 290 PAULARINO AVE This insurance does not apply to "bodily injury" or COSTA MESA CA 92626 "property damage" occurring after: nformation 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 B. With respect to the insurance afforded to these include as an additional insured the person(s) or additional insureds, the following additional organization(s) shown in the Schedule, but only exclusions apply: with respect to liability for "bodily injury", This insurance does not apply to "bodily injury" or "property damage" or "personal and advertising "property damage" occurring after: injury" caused, in whole or in part,_ by: 1. All work, including materials, parts or 1. Your acts or omissions; or equipment furnished in connection with such 2. The acts or omissions of those acting on your work, on the project (other than service, behalf; maintenance or repairs) to be performed by or in the performance of your ongoing operations for on behalf of the additional insured(s) at the the additional insured(s) at the location(s) location of the covered operations has been designated above. completed; or However: 2. That portion of "your work" out of which the 1. The insurance afforded to such additional injury or damage arises has been put to its intended use by any person or organization insured only applies to the extent permitted by other than another contractor or subcontractor law; and engaged in performing operations for a 2. If coverage provided to the additional insured principal as a part of the same project. 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. SOUTHERN CALIFORNIA FLEET SERVICES INC 2855 SAMPSON AVE CORONA CA 92879 © Insurance Services Office, Inc., 2012 Page 1 of 2 CG 2010 04 13 Policy Number: 9823225 Transaction Effective Date: 04-04-2019 C. 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 amount of insurance: 1. Required by the contract or agreement; or 2. Available under the applicable Limits Insurance shown in the Declarations; whichever is less_ This endorsement shall not increase applicable Limits of Insurance shown in Declarations. Page 2 of 2 © Insurance Services Office, Inc., 2012 CG 2010 04 13 Policy Number: 9823225 Transaction Effective Date: 0404-2019 Of the the EXTENSION ENDORSEMENT Extension - CG 20 10 - COSTA MESA SANITARY DISTRICT ANY COVERAGE PROVIDED BY THIS ENDORSEMENT APPLIES ONLY WITH RESPECT TO NAMED INSURED'S SERVICE AND REPAIR OF CERTIFICATE HOLDER'S VEHICLES_ ADDITIONAL INSUREDS ALSO INCLUDE: COSTA MESA SANITARY DISTRICT, THEIR ELECTED AND APPOINTED OFFICIALS, AGENTS, OFFICERS, VOLUNTEERS AND EMPLOYEES IL -F-40-0003 (05-10) Policy Number: 9823225 Transaction Effective Date: 04-04-2019 f 1 f' AC40REIF CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DD/YYYY) Acct#: 2528491 4/10/2019 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 endorsement(s). PRODUCER CONTACT Willis Of Greater Kansas City Inc. PHONE ! FAX IA1C No Ext : 844-290-4908 i AIC No): 5700 W 112th Street, Ste. 100 ADDRESS: BBSlcerts@locktonaffinity.com Overland Park, KS 66211 INSURERS) AFFORDING COVERAGE NAIC # I ( j ! INSURER A: Ace American Insurance Co./,22667 POLICY JE� LOC PRODUCTS -COMP/OP AGG $ INSURED Bar eft Business Services, Inc. INSURER B INSURER C: L/C/F SOUTHERN CALIFORNIA FLEET SERVICES, INC. SO CAL FLEET 8100 NE Parkway Drive, Ste. 200 INSURER D Vancouver, WA 98662 ALL OWNED SCHEDULED BODILY INJURY (Per accident) $ INSURER E : INSURER F: NON -OWNED PROPERTY DAMAGE $ 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 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. !NSR LTR ADDLTYPE OF INSURANCE INSD SUER POLICY NUMBER MM/DDY/YYYY MEFF MlDD ELICY XP 1 LIMITS COMMERCIAL GENERAL LIABILITY j I EACH OCCURRENCE $ j 1 DAMAGE T RENTED CLAIMS -MADE EJ OCCUR PREMISES Ea occurrence $ MED EXP (Any one person) $ PERSONAL & ADV INJURY 1 $ I GEN'L AGGREGATE LIMIT APPLIES PER: I GENERAL AGGREGATE $ I ( j ! POLICY JE� LOC PRODUCTS -COMP/OP AGG $ OTHER: AUTOMOBILE LIABILITY i COMBINED SINGLE LIMIT i $ � i i (Ea accident) 1 BODILY INJURY Per person) 1 $ ANY AUTO ( p ) ALL OWNED SCHEDULED BODILY INJURY (Per accident) $ AUTOS AUTOS ( NON -OWNED PROPERTY DAMAGE $ HIRED AUTOS AUTOS Per accident is UMBRELLA LIAB I ! OCCUR k j EACH OCCURRENCE Is EXCESS LIABCLAIMS-MADE' AGGREGATE $ DED I RETENTION $ ! $ WORKERS COMPENSATION I X PER I OTH- STATUTE ; ER AND EMPLOYERS' LIABILITY Y / N %� ANY PROPRIETOR/PARTNER/EXECUTIVE i E.L. EACH ACCIDENT $ 2,000,000 OFFICER/MEMBER EXCLUDED? ❑ N / A X C65184424 5/1/2018 5/1/2019 t - (Mandatory in NH) E.L. DISEASE - EAEMPLOYEE! $ 2,000,000 dscribe under If yes, e DESCRIPTION OF OPERATIONS below i I E.L. DISEASE - POLICY LIMIT $ 2,000,000 ! DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) Policy State = CA Blanket Waiver of Subrogation in favor of certificate holder when requred by written contract CERTIFICATE HOLDER CANCELLATION Costa Mesa Sanitary District 290 Paularino Avenue Costa Mesa, CA 92626 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25 (2014/01) The ACUKU name and logo are registered marKS of ACUKU Workers' Compensation and Employers' Liability Policy Named Insured Endorsement Number Barrett Business Services, Inc. Policy Number L/C/F SOUTHERN CALIFORNIA FLEET SERVICES, INC. SO CAL FLEET 8100 NE Parkway Drive, Ste. 200 Symbol: Number: C65184424 Vancouver, WA 98662 Policy Period Effective Date of Endorsement 5/1/2018 TO 5/1/2019 4/10/2019 Issued By (Name of the Insurance Company) Ace American Insurance Co. Insert the policy number. The remainder of the information is to be completed only when this endorsement is issued subsequent to the preparation of the policy. CALIFORNIA WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT This endorsement applies only to the insurance provided by the policy because California is shown in Item 3.A. of the Information Page. We have the right to recover our payments from anyone liable for an injury covered by this policy. We will not enforce our right against the person or organization named in the Schedule, but this waiver applies only with respect to bodily injury arising out of the operations described in the Schedule, where you are required by a written contract to obtain this waiver from us. You must maintain payroll records accurately segregating the remuneration of your employees while engaged in the work described in the Schedule. Schedule 1. ( ) Specific Waiver Name of person or organization: (X) Blanket Waiver Any person or organization for whom the Named Insured has agreed by written contract to furnish this waiver. 2. Operations: 3. Premium: The premium charge for this endorsement shall be INCLUDED percent of the California premium developed on payroll in connection with work performed for the above person(s) or organization(s) arising out of the operations described. 4. Minimum Premium: INCLUDED Authorized Agent WC 99 03 22